A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia.
The nurse should follow which of the following guidelines when using an EHR system ?
(Select all that apply.).
Use standardized terminology and abbreviations.
Enter data as soon as possible after providing care.
Share login information with other authorized users.
Review and verify data before saving or submitting.
Correct errors by drawing a single line through them.
Correct Answer : A,B,D
Choice A is correct because using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.
• Choice B is correct because entering data as soon as possible after providing care can ensure the timeliness, completeness, and validity of the information in an EHR system.
• Choice C is wrong because sharing login information with other authorized users can compromise the security, privacy, and integrity of the EHR system. HIPAA guidelines require that each user has a unique identifier and password to access the EHR system.
• Choice D is correct because reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.
• Choice E is wrong because correcting errors by drawing a single line through them is a method used for paper records, not electronic records. Electronic records should have a mechanism to track changes and corrections without altering the original data.
: HIPAA Guidelines for Electronic Medical Records : Electronic Health Records - Health IT Playbook.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.
Choice B is wrong because the nurse should not state opinions about who was responsible for the error.
This could be seen as biased, unprofessional or accusatory.
The nurse should focus on the facts and the causes of the error, not on blaming individuals.
Choice C is wrong because the nurse should not file the report in the client’s medical record.
This could violate the client’s privacy and confidentiality.
The report should be filed in a separate system that is accessible only to authorized personnel.
Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.
This could be premature, unrealistic or inappropriate.
The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.
Correct Answer is C
Explanation
Focus.
Focus charting is a method of organizing health information in an individual’s record using nursing terminology to describe the individual’s health status and nursing actions.The focus of each entry can be a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a key word indicating compliance with a standard of care.
The focus charting method uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response, referred to as DAR.
Choice A is wrong because data is not the term used to begin each entry, but rather the category that describes the subjective and/or objective information supporting the stated focus.Choice B is wrong because problem is not the term used to begin each entry, but rather the nursing diagnosis or collaborative problem on the plan of care.Choice D is wrong because assessment is not the term used to begin each entry, but rather the phase of the nursing process that involves collecting data.
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