Documentation and Health Records Flashcards
6 cards from real Ambulatory Care Test practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Documentation and Health Records flashcards as text
Which component of the EHR is used to document a patient's preferences regarding life-sustaining treatment in ambulatory care?
Answer: Advance directive
Advance directives document a patient's wishes about life-sustaining treatment and should be scanned and stored in the EHR.
What is the primary purpose of medication reconciliation at ambulatory care transitions of care?
Answer: To identify and resolve medication discrepancies between care settings
Medication reconciliation prevents errors by comparing a patient's medication orders across care settings to identify omissions, duplications, and discrepancies.
A nurse documents a patient's pain as 7/10 before and 3/10 after analgesia. Which charting system does this reflect?
Answer: Focus charting (DAR)
Focus charting (DAR: Data, Action, Response) organizes documentation around a patient concern and documents the data, nursing action, and patient response.
Which of the following is an example of a minimum necessary disclosure under HIPAA in ambulatory care?
Answer: Providing only relevant lab results to a referring specialist
The minimum necessary standard requires that only the information required for the specific purpose be disclosed, such as relevant labs to a specialist.
An ambulatory care nurse documents that a patient 'appears anxious.' This is an example of which type of data?
Answer: Objective data
Observable nurse assessments like patient appearance are objective data because they represent directly measurable or observable findings.
Which of the following best describes the purpose of the problem list in an ambulatory EHR?
Answer: To provide a longitudinal summary of active diagnoses and chronic conditions
The problem list serves as a running summary of active and chronic conditions, providing continuity across all encounters in the ambulatory record.