Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
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.).
Using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.
Entering data as soon as possible after providing care can ensure the timeliness, completeness, and validity of the information in an EHR system.
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.
Reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.
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.
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.