Case Studies in Health Information Management
3rd Edition
ISBN: 9781305955332
Author: Patricia Schnering, Nanette B. Sayles, Charlotte McCuen
Publisher: Cengage Learning
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A nurse is administering a pain medication to a patient. In
addition to checking his identification bracelet, the nurse cor-rectly verifies his identity by:
a. Asking the patient his nameb. Reading the patient’s name on the sign over the bedc. Asking the patient’s roommate to verify his named. Asking, “Are you Mr. Brown?”
The LPN/LVN is preparing to take a verbal medication order over the telephone from a health-care provider. For which reason would this action be permitted by the LPN/LVN? The RN is going home with a sudden fever and vomiting. The order is in response to the emergency need for a patient. The LPN/LVN is the only person at the nursing station. The action is supported by both state board and facility policy.
A nurse answers a patient’s call light and finds the patient
on the floor by the bathroom door. After calling for assis-tance and examining the patient for injury, the nurse helps
the patient back to bed and then fills out an incident report.
Which statements accurately describe aspects of this proce-dure? Select all that apply.
a. An incident report is used as disciplinary action againststaff members.b. An incident report is used as a means of identifyingrisks.c. An incident report is used for quality control.d. The facility manager completes the incident report.e. An incident report makes facts available in case litigationoccurs.f. Filing of an incident report should be documented in thepatient record.
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- Below is an example of an ISBAR communication between a registered nurse and a healthcare provider. Which statement represents the "background" in ISBAR?arrow_forwardRewrite the following statements using the appropriate language for nursing documentation. The patient was instructed to ask the nurse for assistance out of bed to the bathroom. The patient willfully disobeyed and got up by herself anyway – she is obviously not concerned about the risk of falling.arrow_forwardIn Medical Care and Emergency Treatment ,Complete the following table with the first aid materials you can see at your home, or materials from a professional medical personnel Case / Situations Definitions Materials Needed Proper Management / Treatment Additional Remarks insect Bite headaches Feverarrow_forward
- The nurse is caring for a dark skin patient. The nurse suspects the patient has a stage 1 pressure injury. Which of the findings will help confirm the nurse conclusionarrow_forwardA hospital infromation system is accessed by the Receptionist ; when a certain patient arrives to the hospital the Receptionist must register his information , thin schedule an appointment if the doctor advise the patient to be admitted to the hospital for certain procedure or operation the Receptionist shall shedule an admission to the patient , ALL admitted patients must be a registered patients ,Furthermore the receotionist should be able to file insurance forms as well as keep the medical reports . identify the Actor(s) from the above scenario ?arrow_forwardA nurse receives a new order from the healthcare provider to keep the client nothing by mouth (NPO). which member(s) of the healthcare team need to be alerted to the new NPO order? Select all that apply. case manager respiratory therapist dietary personnel wound care nurse unlicensed assistive personnelarrow_forward
- A PATIENT’S RECORD UNDERWENT REVIEW BECAUSE THE OUTPATIENT DIAGNOSIS ABOUT MULTIPLE INJURIES WAS UNCLEAR. WHO IS AUTHORIZED TO CLARIFY THE DIAGNOSIS? HEALTH CARE PROVIDER HIM SUPERVISOR INSURANCE COMPANY OUTPATIENT CODERarrow_forwardWhen completing a safety event report, the nurse should:a. Include suggestions on how to prevent the incident fromrecurring.b. Provide minimal information about the incident.c. Discuss the details with the patient before documentingthem.d. Objectively describe the incident in detail.arrow_forwardWhen a patient is being admitted from home, the social worker should arrange for the medical records on the patient's last hospitalization. the facility should begin recording the patient's past history and background. prior medical records are generally not available. the social worker should obtain medical records from the admitting physician's office.arrow_forward
- A physician requests that you change the “date of dictation” on a medical report to 3 days before the actual date of dictation so that the report will appear to have been dictated in a timely fashion. He explains that he was called out of town for a family emergency and fell behind in his dictation, and that he appreciates your cooperative and helpful attitude with small requests such as this. What do you do?arrow_forwardA medical assistant who does not meet the expected standard of care may be charged with professional _______?arrow_forwardDuring rounds, a charge nurse hears the patient care techni-cian yelling loudly to a patient regarding a transfer from the bed to chair. When entering the room, what is the nurse’s bestresponse? a. “You need to speak to the patient quietly. You are disturb-ing the patient.” b. “Let me help you with your transfer technique.”c. “When you are finished, be sure to apologize for yourrough demeanor.”d. “When your patient is safe and comfortable, meet me atthe desk.”arrow_forward
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The Psychology of Violent Behaviour; Author: Simon Fraser University;https://www.youtube.com/watch?v=iTdqo_7_qLE;License: Standard Youtube License