A nurse is preparing to document a client's information in the electronic medical record.
Which of the following nursing statements identifies the purpose of documentation?

"Documentation enables providers to monitor the nurse.”.

"Documentation provides a communication tool for the health care team.”.

"Documentation provides information for a client audit.”.

"Documentation facilitates reimbursement from the local government.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.

Choice B rationale

Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.

Choice C rationale

Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.

Choice D rationale

While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.

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Correct Answer is B

Explanation

Choice A rationale

While electronic medical records (EMRs) improve legibility by using standardized digital text, they do not entirely eliminate the need to interpret physician notes or potential data entry errors. Clinicians still input information, and nuances in terminology or abbreviations can require careful review. EMRs primarily address the issue of illegible handwriting associated with paper-based records.

Choice B rationale

Electronic medical record systems streamline documentation processes by offering templates, drop-down menus, and the ability to copy forward information. This reduces the need for repetitive manual charting, freeing up nurses' time for direct patient care and other essential tasks. Efficient data entry and retrieval contribute significantly to time savings in documentation.

Choice C rationale

Password management is a security feature of computer systems, including EMRs, and often requires periodic changes to protect patient data. Implementing a new EMR system does not typically eliminate the need for password changes; in fact, it might introduce new password protocols. Security protocols necessitate regular password updates to maintain data integrity and confidentiality.

Choice D rationale

Accessing a family member's medical record violates patient privacy and confidentiality regulations, such as HIPAA. Nurses should only access records of patients for whom they are directly providing care. Viewing a son's medical record without a professional need is an ethical and legal breach of patient confidentiality.

A. Listen to the patient's lung sounds and check the pulse oximetry level. B. Tell the patient that the physician will be in shortly to start treatment. C. Pull the curtain around the bed and ensure patient privacy. D. Reassure the patient that the shortness of breath will be relieved shortly.

Correct Answer is A

Explanation

Choice A rationale

Assessing the patient's respiratory status with auscultation of lung sounds and pulse oximetry provides immediate and critical information about the severity of the shortness of breath and the patient's oxygenation. This data is essential for guiding immediate interventions and further assessment. Normal pulse oximetry is typically 95-100%.

Choice B rationale

Telling the patient the physician will be in shortly does not address the immediate distress of acute shortness of breath and delays necessary assessment and intervention. It offers false reassurance without taking any immediate action.

Choice C rationale

While ensuring patient privacy is important, it is not the priority action in a situation of acute shortness of breath. Addressing the immediate physiological compromise takes precedence over privacy concerns at the initial moment of assessment.

Choice D rationale

Reassuring the patient that the shortness of breath will be relieved shortly, without any assessment or intervention, is inappropriate and potentially dangerous. It does not address the underlying cause and may delay necessary treatment.

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A nurse is preparing to document a client's information in the electronic medical record.Which of the following nursing statements identifies the purpose of documentation?

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A nurse is preparing to document a client's information in the electronic medical record.
Which of the following nursing statements identifies the purpose of documentation?