Documentation and Informatics Paper
12. You are helping to design a new patient discharge teaching
sheet that will go home with patients who are discharged to
home from your unit. Which of the following do you need to
remember when designing the teaching sheet?
1. The new federal laws require that teaching sheets be
e-mailed to patients after they are discharged.
2. You need to use words the patients can understand when
writing the directions.
3. The form needs to be given to patients in a sealed envelope
to protect their health information.
4. The names of everyone who cared for the patient in the
hospital need to be included on the form in case the patient
has questions at home.
13. A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert
warning appears on the screen warning the nurse that this
patient is at a high risk for aspiration because the head of the
bed is not elevated high enough. This warning is known as
what type of system?
1. Electronic health record
2. Clinical documentation
3. Clinical decision support system
4. Computerized physician order entry
14. While reviewing the pulmonary section of a patient’s
electronic chart, the physician notices blank spaces since the
initial assessment the previous day when the nurse documented that the lung assessment was within normal limits.
There also are no progress notes about the patient’s respiratory
status in the nurse’s notes. The most likely reason for this
1. The nurses forgot to document on the pulmonary system.
2. The nurses were charting by exception.
3. The computer is not working correctly.
4. The physician does not have authorization to view the
15. What is an appropriate way for a nurse to dispose of printed
1. Rip several times and place in a standard trash can
2. Place in the patient’s paper-based chart
3. Place in a secure canister marked for shredding
4. Burn the documents
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