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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Developed by an RN:
This option suggests that an RN (Registered Nurse) is solely responsible for creating the initial care plan. While nurses significantly contribute to the care plan, it is often a collaborative effort involving various healthcare professionals, including doctors, nurses, and other specialists.
B. Completed on the day of admission:
This choice means that the initial care plan, outlining the patient's immediate healthcare needs and interventions, is developed and documented on the day the patient is admitted to the healthcare facility. It's essential to establish a plan promptly to ensure the patient receives appropriate and timely care.
C. Used as the basis of care throughout a hospital stay without alteration:
This option suggests that the initial care plan remains unchanged throughout the patient's hospital stay. However, healthcare plans need to be dynamic, adapting to the patient's evolving condition. Care plans are continuously assessed and modified based on the patient's response to treatments and interventions.
D. Developed by the primary care provider and incorporated into the nursing care:
This choice implies that the initial care plan is created by the primary care provider (which could be a doctor) and then integrated into the nursing care. While doctors provide medical diagnoses and orders, nurses play a crucial role in implementing and coordinating the care plan, ensuring the patient's needs are met.
Correct Answer is D
Explanation
A. "Don't worry; this pain won't last forever."
This statement dismisses the patient's concerns and does not encourage open communication about pain. It does not address the patient's current pain experience or provide a basis for effective pain management.
B. "You look pretty comfortable. Are you having any pain?"
While this statement attempts to inquire about the patient's pain, it might not encourage the patient to open up about their pain experience. The patient might downplay their pain to appear strong or not to be a bother.
C. "Is this pain the same as the pain you had yesterday?"
This question is specific and might help in assessing the consistency and nature of the pain. However, it assumes the patient had pain yesterday and does not open the conversation effectively for the patient to express their pain experience freely.
D. "Tell me about the pain you've been having."
This statement is open-ended and encourages the patient to express their pain experience in their own words. It creates a comfortable environment for the patient to discuss their pain, allowing the nurse to gather valuable information about the pain's intensity, location, quality, and factors that aggravate or alleviate it. This approach is patient-centered and allows for a comprehensive pain assessment.
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