Deck 7: Documentation

Question 1

When events are not consistent with facility or national standards of expected care,the form that explains the lapse is the:

A) subjective data.
B) focus chart.
C) incident report.
D) nursing assessment.

Answer 1

incident report.

Question 2

The process used to appraise the practice of an individual nurse is called:

A) quality assurance.
B) incident reporting.
C) OBRA.
D) peer review.

Answer 2

peer review.

Question 3

When focus charting,what does the nurse use as a basis for documentation?

A) Problem list
B) Nursing orders
C) Nursing diagnoses
D) Evaluation

Answer 3

Nursing diagnoses

Question 4

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

A) Charting in code
B) Logging off
C) Charting in privacy
D) Signing on with a password

Question 5

A system that classifies patients by age,diagnosis,and surgical procedure and produces 300 different categories used for predicting the use of hospital resources is known as:

A) quality assurance.
B) resource assessment.
C) quality improvement.
D) diagnosis-related groups.

Question 6

Standards for long-term care documentation are regulated by:

A) OBRa.
B) Title XXII.
C) nursing diagnoses.
D) the care plan.

Question 7

When using the data,action,response,education (DARE)system of charting,the data portion focuses on:

A) planning.
B) assessment.
C) implementation.
D) patient teaching.

Question 8

In managed care,documentation is especially significant because:

A) the hospital needs to show that employees care for patients.
B) institutions are reimbursed only for patient care that is documented.
C) patients might bring lawsuits if care was not given.
D) documents may become part of a lawsuit.

Question 9

Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:

A) provide information only to another nurse.
B) provide information only to an attorney.
C) share information only with the family.
D) have a clinical reason for reading the record.

Question 10

Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the nursing diagnoses identified?

A) Physician
B) Registered nurse
C) Nursing assistant
D) Licensed practical nurse/licensed vocational nurse

Question 11

If the nurse makes an error while documenting in a patient's chart,the nurse should:

A) scratch out the error.
B) apply correction fluid.
C) erase the error completely.
D) draw a single line through the error.

Question 12

When documenting in a patient's chart,the nurse should:

A) include speculation.
B) chart consecutively.
C) leave blank spaces.
D) include retaliatory comments.

Question 13

When the nurse charts only additional treatments done,changes in patient condition,and new concerns,the system of documentation is:

A) SOAP.
B) block.
C) CBE.
D) focus.

Question 14

Documentation is necessary for the evaluation of patient care and is an integral part of the nursing process phase of:

A) assessment.
B) planning.
C) implementation.
D) evaluation.

Question 15

The nurse knows that for a hospitalized patient,the legal owner of the patient's medical record is the:

A) patient.
B) physician.
C) institution.
D) state.

Question 16

The documentation format that uses the acronym SOAPE is:

A) problem-oriented.
B) focused.
C) traditional.
D) crisis.

Question 17

Home health care documentation is unique because:

A) some charting is retained at the hospital.
B) the physician's office needs separate charting.
C) different health care providers need access.
D) the physician is the pivotal person in the charting.

Question 18

Documentation of type of care,time of care,and signature of the person who is documenting proves that:

A) the person who signed the documentation did all the work noted.
B) no litigation can be brought against the person who signed.
C) interventions were implemented to meet the patient's needs.
D) the patient's response to the intervention was positive.

Question 19

When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type,it is known as a:

A) nursing order.
B) Kardex.
C) nursing care plan.
D) critical pathway.

Question 20

The purpose of QA (quality assurance)is to:

A) screen employment applications.
B) evaluate care results against accepted standards.
C) conduct in-services for "quality documentation."
D) report deviation from standards to the state health department.

Question 21

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

Question 22

What should a medical record provide for all health care providers? (Select all that apply.)

A) Care given to the patient
B) Care planned for the patient
C) A patient's nursing problems
D) A patient's medical problems
E)Details about any incident reports
F)The patient's response to treatment

Question 23

What are the basic purposes of written patient records? (Select all that apply.)

A) Teaching
B) Legal record of care
C) Written communication
D) Research and data collection
E)Permanent record for accountability
F)Temporary record of hospitalization

Question 24

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

Question 25

The best defense against malpractice claims associated with nursing care is accurate _____________.

Question 26

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

A) Description of injury,including diagrams of injury placement
B) Date,time,and location of incident
C) Name of physician and family members notified
D) Chronological order of events of the incident
E) Confirmation that an incident report was initiated

Question 27

What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.)

A) Incorrectly recording the time of an event
B) Failing to record verbal orders
C) Charting events in advance
D) Documenting an incorrect date
E) Marking out and initialing charting errors

Question 28

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

Question 29

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

A) Security
B) Expense of training staff
C) Legibility
D) Easy retrieval
E) New terminology