A charge nurse is providing an in-service on documentation with a group of staff nurses. Which of the following should the nurse include as a component of an electronic health record?
Demographic data
Billing payments
Driver's license
Facility policies
The Correct Answer is A
A. Demographic data. An electronic health record (EHR) includes demographic information such as the client’s name, date of birth, contact details, and medical history. This data helps healthcare providers personalize care and ensure accurate record-keeping.
B. Billing payments. While healthcare facilities may have electronic billing systems, financial transactions and payments are not considered a core component of the EHR, which primarily focuses on clinical documentation and patient care.
C. Driver's license. A driver's license may be used for identity verification during registration, but it is not a required component of an EHR. Identifying information is documented separately from clinical records.
D. Facility policies. EHRs store patient-related health information rather than institutional policies. Facility policies are typically maintained in administrative systems or policy manuals, separate from patient medical records.
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Related Questions
Correct Answer is A
Explanation
A. Clinical practice guidelines for the management of high blood pressure. Clinical practice guidelines provide evidence-based recommendations for hypertension management, including lifestyle modifications, dietary changes, exercise, and pharmacologic interventions. These guidelines are the best resource for health promotion activities.
B. Acute care facility protocol for clients who are experiencing a hypertensive crisis. This protocol focuses on emergency management of severe hypertension rather than preventive strategies. While important in acute care settings, it is not the most relevant resource for general health promotion.
C. Standards of care for monitoring clients who have a history of blood pressure elevation. Standards of care outline nursing responsibilities for assessing and monitoring clients with hypertension but do not necessarily provide comprehensive health promotion strategies.
D. A critical pathway for clients who have had a stroke. Critical pathways are structured care plans used for managing specific conditions, such as stroke recovery, but they are not primarily focused on preventing hypertension or promoting overall health in hypertensive clients.
Correct Answer is C
Explanation
A. TJC is an organization that monitors insurance claims. The Joint Commission does not oversee insurance claims or reimbursement processes. Its primary role is to evaluate and accredit healthcare organizations to ensure they meet safety and quality standards.
B. TJC provides licensure for health care providers. TJC does not issue professional licenses; this is the responsibility of state licensing boards and regulatory agencies. Instead, TJC focuses on accrediting healthcare organizations to ensure they meet established quality and safety standards.
C. TJC provides accreditation to facilities. The Joint Commission accredits hospitals, long-term care facilities, and other healthcare organizations, ensuring they meet national patient safety and quality standards. Accreditation by TJC signifies compliance with best practices and can impact funding and reputation.
D. TJC is a for-profit organization. TJC is a non-profit organization that works to improve healthcare quality and safety. Its accreditation process is designed to promote excellence in patient care rather than generate profits.
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