When using electronic medical records (EMR), the nurse knows that the EMR:
a. holds the documentation of a single episode of care.
b. is a longitudinal record of care for each patient.
c. is widely used for individual health care encounters.
d. includes progress notes for all disciplines.
ANS: A
The electronic medical record (EMR), which is the documentation of a single episode of care (i.e., outpatient visit or inpatient stay), becomes a part of the electronic health record (EHR), which is a longitudinal record of care. EHRs are becoming widely used for individual health care encounters and for maintaining patients' health records over long periods. As EHRs become fully implemented, they include provider order entries, progress notes for all disciplines, computerized medication profiles, access to diagnostic test results on a timely basis, decision support systems, and online clinical reminders and alerts.
You might also like to view...
The nursing assistants are refusing to care for D.J. Martin, 78 years old, because he hits at them whenever they try to move him from his bed into his chair. Mr. Martin has Alzheimer's disease and becomes very agitated at times during bathing
What is the best response by the licensed practical nurse? a. Tell the staff that they can take turns caring for Mr. Martin and set up a revolving assignment schedule b. Approach Mr. Martin's family and tell them that his behavior is unacceptable and if he does not stop hitting nursing assistants he will have to be restrained c. Transfer Mr. Martin to another section of the nursing home to take the stress off of the nursing assistants who have been caring for him since his admission d. Review the plan of care with the interdisciplinary team to develop strategies to decrease Mr. Martin's agitation during bathing
A nursing diagnosis of: Knowledge, deficient, related to relationship of infection to nutritional needs is critical because:
a. The body requires more protein intake to fight infection. b. The body does not absorb nutrients effectively postoperatively. c. The body does not require more calories postoperatively. d. The body requires more parenteral nutrients postoperatively.
Two days after having coronary bypass grafting, a patient develops atrial fibrillation. The patient is tolerating the rhythm. What is the nurse's initial action?
1. Have the patient cough. 2. Do an electrocardiogram (ECG). 3. Increase the patient's IV rate. 4. Notify the health care provider.
The medical diagnosis is the name given to a disease process
Indicate whether the statement is true or false