Ambulatory Care Test Documentation and Health Records 2

Question 1

Which component of the EHR is used to document a patient's preferences regarding life-sustaining treatment in ambulatory care?

Accepted Answer

Advance directive

Answer

Advance directives document a patient's wishes about life-sustaining treatment and should be scanned and stored in the EHR.

Question 2

What is the primary purpose of medication reconciliation at ambulatory care transitions of care?

Accepted Answer

To identify and resolve medication discrepancies between care settings

Answer

Medication reconciliation prevents errors by comparing a patient's medication orders across care settings to identify omissions, duplications, and discrepancies.

Question 3

A nurse documents a patient's pain as 7/10 before and 3/10 after analgesia. Which charting system does this reflect?

Accepted Answer

Focus charting (DAR)

Answer

Focus charting (DAR: Data, Action, Response) organizes documentation around a patient concern and documents the data, nursing action, and patient response.

Question 4

Which of the following is an example of a minimum necessary disclosure under HIPAA in ambulatory care?

Accepted Answer

Providing only relevant lab results to a referring specialist

Answer

The minimum necessary standard requires that only the information required for the specific purpose be disclosed, such as relevant labs to a specialist.

Question 5

An ambulatory care nurse documents that a patient 'appears anxious.' This is an example of which type of data?

Accepted Answer

Objective data

Answer

Observable nurse assessments like patient appearance are objective data because they represent directly measurable or observable findings.

Ambulatory Care Test Practice Test

Ambulatory Care Test Practice Test

Ambulatory Care Test Documentation and Health Records 2