Deck 4: Documentation and Informatics

Question 1

To limit liability,nursing documentation must clearly indicate that the nurse provided individualized,goal-directed nursing care to a patient based on the _____________________.

Answer 1

nursing assessment

Question 2

The abbreviation for every day (___)is no longer used.

Answer 2

qd

Question 3

Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?

A)Document the 1000 vital signs in the graphic record only.
B)Not report the incident because it was a transient episode.
C)Document the vital signs in the graphic and progress record.
D)Document the vital signs as 12 o'clock signs.

Answer 3

Document the vital signs in the graphic and progress record.

Question 4

Which of the following is the best example of objective charting?

A)"The patient states that he has been having severe chest discomfort."
B)"The patient is lying in bed and seems to be in considerable pain."
C)"The patient appears to be pale and diaphoretic and complains of nausea."
D)"The patient's skin is ashen and respiratory rate is 32 and labored."

Question 5

Nursing documentation:

A)ensures continuity of care.
B)provides legal evidence.
C)evaluates patient outcomes.
D)increases the risk of litigation.

Question 6

Which of the following is the best example of accurate documentation?

A)"Abdominal wound is 5 cm in length without redness,edema,or drainage."
B)"OD to be irrigated qd with NS."
C)"No complaint of abdominal pain this shift."
D)"Patient watching TV entire shift."

Question 7

The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be:

A)the standardized care plan.
B)the acuity record.
C)the patient care summary.
D)flow sheets.

Question 8

The patient has been transferred to the nursing home from the acute care hospital.A report was called from the hospital and was received by the RN in charge of the nursing home unit.Upon arrival,which approach is used to assess the patient?

A)The Long-Term Care Facility Resident Assessment Instrument
B)The case-management model
C)Collaborative pathways
D)The charting by exception model

Question 9

The nursing assistant tells the RN that when the patient's vital signs were taken,the patient complained that she was in a lot of pain.The nursing assistant then tells the nurse that she charted the patient's complaint when she charted the vital signs.What instruction does the nurse need to provide to the nursing assistant?

A)The nursing assistant needs to make sure she uses the SBAR format when entering notes.
B)Nursing assistants are not allowed to chart vital signs.
C)Only the nurse can write in the progress notes.
D)The nursing assistant needs to write using blue ink to distinguish from the RN note.

Question 10

The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any)?

A)Complete an incident report and put it in the medical record.
B)Chart what happened and state that an incident report has been filled out.
C)Do nothing because the patient was not harmed.
D)Document what happened in the patient record without mentioning the incident report.

Question 11

Nursing documentation must have which of the following characteristics?

A)Factual
B)Organized
C)Public
D)Complete

Question 12

Which is a primary difference between home care and hospital care?

A)Documentation systems need to provide information for the home health nurse only.
B)Documentation no longer affects reimbursement.
C)Services are assumed and need less documentation.
D)The patient and the family witness most of the care provided.

Question 13

The patient has been in the hospital for a hip replacement.According to his critical pathway,he should have his Foley catheter discontinued on the fourth day after surgery.Instead,the patient has it removed on the third day and is voiding normally with no problems.This would be a sign of:

A)a negative variance.
B)positive case management.
C)a positive variance.
D)use of SBAR.

Question 14

__________________ documentation should include your observations of patient behavior.

Question 15

What is the goal of information management?

A)Support decision making.
B)Improve patient outcomes.
C)Ensure patient safety.
D)Improve health care documentation.

Question 16

The patient is ready to go home from the hospital.What does the nurse provide to the patient and his family before he leaves the facility?

A)Discharge summary
B)Standardized care plan
C)Patient care summary
D)Flow sheet

Question 17

Which is an acceptable format to use in documentation?

A)SOAPIE
B)HIPAA
C)DAR
D)EHR

Question 18

The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?

A)The patient's parents
B)The patient's significant other only
C)No one in the hospital until the patient says so
D)The patient's physician,significant other,and laboratory personnel

Question 19

A patient's private health information is legally protected by the ________________.

Question 20

A preprinted guideline used to care for patients with similar health problems is known as the:

A)acuity record.
B)standardized care plan.
C)patient care summary.
D)flow sheet.

Question 21

________________ provide a quick,easy reference for health care team members in assessing the patient's status.

Question 22

___________________ provide a format for documenting a patient's health status and progress.

Question 23

When making written entries in the patient's medical record,describe the nursing care provided and the ____________.

Question 24

Multidisciplinary care plans that include key interventions and expected outcomes within an established time frame are known as _______________.

Question 25

Standardized care plans are effective ways to plan care for the patient.To be most effective,however,the SCP must be _________________.