The electronic health record (EHR) is used to document client ...

[mmm]

The electronic health record (EHR) is used to document client care management. Which statement(s) below is/are applicable to EHR? Select all that apply.
 
  a. Increases the potential for breaches in confidentiality
  b. Decreases the time spent to complete documentation
  c. Minimizes medical errors through use of alert systems
  d. Communicates the client's plan of care to the healthcare team

Question 2

The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT).
 
  At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply.
  a. Notify the prescriber before giving the medication.
  b. Give subcutaneous heparin as ordered.
  c. Hold the medication dose at this time.
  d. Chart the reason the medication was not given.
  e. Assess for other significant signs and symptoms.
  f. Record abnormal findings in the patient's health record.

[dudman123]

Answer to Question 1

B, C, D
The EHR streamlines many documentation steps, making written communication concise and standardized. Electronic access to the patient's health record increases confidentiality and security of information by using customized passwords for each healthcare professional to limit access to the records. Time for documentation is decreased as the nurse becomes more comfortable using electronic documentation. Medical errors are decreased owing to programmed alerts that are automatically displayed when a healthcare provider takes an action that could potentially be harmful to the client. The EHR facilitates communication of client care across the healthcare team because all of the information is in one place and multiple people can access it from different computers at the same time.

Answer to Question 2

C, D, E, F
Heparin, an anticoagulant, should be given to achieve one and a half to two times the normal clotting times and PTT. Because the findings of the laboratory values are four times the normal range and petechiae are present, this indicates a significant risk for bleeding. Therefore, the heparin should be held; the physician should be notified immediately. The nurse must document why the medication was not given and should assess for other significant findings. Omitted or delayed administration must be charted as soon as possible with an explanation for the delay or omission. The nurse will notify the provider but not give the medication. Heparin is given via a subcutaneous injection; however, because it is being held, it will not be administered or documented as given. Because the findings regarding the heparin and its use are abnormal, the nurse would not document normal findings.