The electronic medical record was set up as a goal of the 2009 American Recovery and Reinvestment Act, for the purpose of providing a:
comprehensive plan to allow patient access to medical records.
comprehensive document of health care costs.
comprehensive plan of care for all patients.
Correct comprehensive record of a patient's history and care across all facilities and admissions.
The Correct Answer is D
A. Comprehensive plan to allow patient access to medical records.
While electronic medical records (EMRs) do facilitate patient access to their medical information, the primary goal of the 2009 American Recovery and Reinvestment Act was broader. It aimed to improve healthcare quality, safety, and efficiency through the promotion of health IT, including EMRs.
B. Comprehensive document of health care costs.
Although EMRs can include billing information, the main purpose of EMRs is to record clinical data for patient care and not specifically to document healthcare costs.
C. Comprehensive plan of care for all patients.
EMRs are tools used by healthcare providers to record patient information and manage healthcare delivery. While they can support the creation and management of care plans, their primary function is to store patient data electronically rather than generating care plans.
D. Correct comprehensive record of a patient's history and care across all facilities and admissions.
This statement best reflects the primary goal of the electronic medical record implementation. EMRs are designed to provide accurate, comprehensive, and up-to-date information about a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results, among other essential data. They ensure that this information is accessible to authorized healthcare providers across various facilities and admissions, improving continuity of care and patient safety.
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Correct Answer is C
Explanation
A. Orders for diagnostic and therapeutic procedures such as laboratory tests or x-rays:
This refers to medical orders, which are instructions given by a physician for diagnostic tests or treatments. These orders are not part of the nursing care plan. Nurses execute these orders but do not create them.
B. Laboratory and x-ray reports, pathology reports, and the medication record:
These are patient records and reports. While nurses use this information to inform their care, the reports themselves are not the nursing care plan. Nurses analyze these reports to make informed decisions regarding patient care.
C. Nursing orders for individualized interventions to assist the patient to meet expected outcomes:
This is the correct choice. Nursing care plans involve identifying the patient's nursing diagnoses (health issues that nurses can address), setting specific and measurable outcomes, planning interventions tailored to the patient's needs, and evaluating the outcomes. It's a holistic approach designed to address the patient's unique health challenges.
D. The physician's history and physical examination, as well as medical diagnoses:
This refers to the medical diagnosis and assessment, which are critical for understanding the patient's overall health. While nurses consider this information, the nursing care plan specifically focuses on nursing interventions and care strategies, making it distinct from the medical diagnosis.
Correct Answer is B
Explanation
A. The case management system:
Case management involves coordinating comprehensive healthcare services for patients across different settings and healthcare professionals.
This choice doesn't describe the specific style of documentation used in the scenario provided.
B. SOAP Note:
Subjective: Information reported by the patient, like feelings or symptoms.
Objective: Observable and measurable data, such as physical examination findings.
Assessment: The nurse's professional judgment about the patient's condition.
Plan: Interventions and treatments planned for the patient.
In the scenario, the documentation includes subjective information (patient denies itching, happy with improvement), objective data (rash fading, no visible hives), the nurse's assessment (skin integrity improving), and the plan (check rash daily until discharge). This aligns with the structure of a SOAP note.
C. Narrative style:
Narrative charting involves writing out the patient's story in a paragraph form.
While it can contain similar information to a SOAP note, it doesn't follow the structured format of SOAP (Subjective, Objective, Assessment, Plan) and tends to be more detailed and descriptive.
D. Charting by exception:
Charting by exception involves documenting only abnormal findings or significant events.
This method reduces redundant documentation, focusing on deviations from the expected or normal findings.
The scenario provides a mix of both normal (improvement in skin, patient satisfaction) and abnormal (initial rash and hives) findings, so it's not solely charting by exception.
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