Question 1

Advantages of source-oriented or narrative charting include all of the following except that it:
A) encourages documentation of normal and abnormal findings.
B) gives information on the patient's condition and care in chronological order.
C) indicates the patient's baseline condition for each shift.
D) includes aspects of all steps of the nursing process.

Accepted Answer

A disadvantage of source-oriented, or narrative, charting is that it encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information.

Question 2

The nurse is with a patient who complains of severe pain, documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patient's primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to:
A) cause the primary care provider to come to the attention of the hospital administration.
B) be questioned by the nurse's supervisor for time inefficiency.
C) be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain.
D) justify insurance reimbursement for an extended duration of hospitalization for the patient.

Accepted Answer

Documentation of complications or a patient's changing condition is used by insurance companies to justify payments for hospitalization. Documentation also serves as evidence of standards of care in a court of law.

Question 3

If an agency is using computer-assisted charting, the nurse is responsible for:
A) learning the passwords of the staff nurses and primary care providers so that they can communicate with one another.
B) guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal.
C) patient education to input information about herself, such as intake and output or symptoms the patient may experience.
D) choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation.

Accepted Answer

Confidentiality of computer records is as important as that of the paper medical record. Nurses must also be protective of their user passwords.

Question 4

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:
A) effective communication.
B) informatics.
C) familiarity with medical terms.
D) writing nursing care plans.

Accepted Answer

The Quality and Safety Education for Nurses (QSEN) project has identified informatics as an important pre-licensing skill.

Question 5

The nurse understands that a face sheet contains information pertaining to:
A) serial measurements and observations, such as temperature, pulse, respiration, blood pressure, and weight.
B) plan of care for the patient, including nursing diagnoses, goals/expected outcomes, and nursing interventions.
C) written report of the nursing process, record of interventions implemented, and the patient's response to them.
D) patient data, including patient's name, address, phone number, insurance company, and admitting diagnosis.

Accepted Answer

The type of information contained on a face sheet includes patient data, including the patient's name, address, phone number, next of kin, hospital identification number, religious preference, place of employment, insurance company, occupation, name of admitting physician, and admitting diagnosis.

Question 6

A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:
A) "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
B) "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
C) "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
D) "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."

Accepted Answer

When documenting a sign or symptom, the nurse should include the quality (levels 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms.

Question 7

Which examples of documentation would be most informative to transcribe to the patient's medical record?
A) "Patient consumed two slices of bread and a cup of coffee at breakfast."
B) "Patient does not appear to be hungry after consuming breakfast."
C) "Patient ate a small amount of bread and drank a little coffee for breakfast."
D) "Patient ate well for breakfast, lunch, and dinner and seems content."

Accepted Answer

Use of the words "appears to" or "seems" in phrases such as "appears to be resting" should be avoided. Document the behavior; the patient either is or is not resting. Words that have ambiguous meanings and slang should not be used in documentation. For example, how much is "a little," "a small amount," or a "large amount"? What do phrases such as "ate well" and "taking fluids poorly" mean? Although such words give a general idea of what is meant, they are not specific.

Question 8

A nurse understands that the primary care provider's directives for patient care are also referred to as the:
A) history and physical.
B) primary care provider's orders.
C) progress notes.
D) face sheet.

Accepted Answer

The primary care provider's directives for patient care are the same as the physician's orders.

Question 9

In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents "Subjective: denies itching. Happy with improvement in skin.
Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge.” This type of documentation is an example of:
A) charting by exception.
B) narrative style.
C) a problem-oriented medical record (POMR).
D) the case management system.

Accepted Answer

The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP (subjective, objective, assessment, plan) format as shown here.

Question 10

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:
A) at the end of the shift so that the nurse can give his full attention and time to the patient's needs during the shift.
B) a nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities.
C) at least three times during the shift: at the beginning, in the middle, at the end, and as needed.
D) an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.

Accepted Answer

An initial assessment should be performed at the beginning of the shift and promptly documented. It will determine the plan and priorities. Documentation should be done as close to the time of occurrence as possible.

Question 11

The nurse uses the flow sheet in patient care documentation primarily:
A) to track routine assessments, treatments, and frequently given care.
B) to eliminate written narratives and to save time.
C) in computer-assisted charting to create visual graphs showing change.
D) to improve continuity of care and exchange of information among disciplines.

Accepted Answer

Flow sheets are a time saver but do not eliminate narrative charting. They are used to document information that is routine and that would be "lost" in a narrative note.

Question 12

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:
A) "Certainly. This hospital doesn't need to keep it if you are leaving and will not be returning here."
B) "You are entitled to the information in your medical record, but the medical record is the property of the hospital. I will see about having a copy made for you."
C) "The information in your medical record is confidential, and you cannot leave this facility with it."
D) "Because you are leaving against the medical advice of your primary care provider, you may not have the medical record."

Accepted Answer

The medical record is the property of the facility, but the patient has a legal right to the information in it even if she is leaving AMA.

Question 13

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) documentation is that charting by exception:
A) is well suited to defending nursing actions in court.
B) contains important data certain to be noted in the narrative sections.
C) allows staff to learn the system quickly and easily.
D) highlights abnormal data and patient trends.

Accepted Answer

Charting by exception enables staff to see notation of changes in a patient's condition at a glance.

Question 14

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:
A) motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience.
B) doing appropriate research about nursing care as long as information is not divulged.
C) violating the confidentiality of the patient's record.
D) neglecting the assigned patient load and should read the unassigned patient's medical record only after his assigned work is completed.

Accepted Answer

A person reading a patient's chart who is not involved in the patient's care is in violation of confidentiality. Protecting the patient's privacy is of prime importance.

Question 15

A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: "Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication." This documentation is:
A) an example of charting by exception.
B) evidence of the use of the nursing process.
C) using the problem-oriented medical record (POMR) format.
D) usually entered on a flow sheet for treatments and vital signs.

Accepted Answer

The nursing process is evident in this documentation. Assessment, interventions, and evaluation are all noted.

Question 16

When the nurse documents in narrative or source-oriented format about the patient's condition and the nursing care provided, it is appropriate for him to record:
A) "Patient will go to physical therapy after lunch."
B) "Diabetes in excellent control. Continue with current insulin schedule."
C) "I gave the patient a thorough bath and cut her fingernails."
D) "To x-ray by wheelchair at 10:30 AM IV infusing in left arm."

Accepted Answer

Documentation that includes specific information regarding time, method of travel, destination, and current status (that an IV medication is infusing) is a clear example of source-oriented charting.

Question 17

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:
A) nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career.
B) actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared.
C) nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.
D) nurse has not violated the confidentiality of the patient because the patient is terminal; sharing this information will not harm the patient.

Accepted Answer

As a legal record, the contents of the medical record must be kept confidential and can be given out only with the patient's written consent because it contains personal information regarding the patient. Only those health professionals caring directly for the patient, or those involved in research or education, should have access to the chart. Protecting the privacy of the patient is of prime importance. Patient information is not discussed with others who are not directly involved in the patient's care.

Question 18

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
A) "4 cm reddened area over sacrum. Skin intact, warm, and dry."
B) "Taking fluids poorly, but more than yesterday."
C) "Apparently comfortable all night. Offers no complaints of pain."
D) "Patient says she is still slightly nauseated, would like to try some toast and tea."

Accepted Answer

Provision of specific objective data-size, location, and characteristics of the patient's skin-is clear and brief and informative.

Question 19

A nurse enters a notation in a patient's medical record but then discovers that the notation was made in the wrong chart. The nurse correctly:
A) draws a single line through the notation so that it is still readable and writes "mistaken entry," his signature, and the date and time.
B) removes the page on which the error is located and documents the other correct notes.
C) blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
D) whites out the wrong entry and writes the note in the chart of the correct patient.

Accepted Answer

When an error is made, no attempt to hide or obliterate the error should be made, because this may be questioned in a court of law.

Question 20

A resident in a skilled nursing facility for a short term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
A) "Refuses to have blood drawn. Doctor notified."
B) "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
C) "Doctor notified of failure to draw ordered blood work."
D) "Blood not drawn because tests are no longer desired by patient."

Accepted Answer

When a patient refuses a treatment, the nurse should document the exact words of the patient regarding why the patient is refusing care.

Quiz 7: Documentation of Nursing Care

Advantages of source-oriented or narrative charting include all of the following except that it:

If an agency is using computer-assisted charting, the nurse is responsible for:

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

The nurse understands that a face sheet contains information pertaining to:

A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:

Which examples of documentation would be most informative to transcribe to the patient's medical record?

A nurse understands that the primary care provider's directives for patient care are also referred to as the:

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

The nurse uses the flow sheet in patient care documentation primarily:

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) documentation is that charting by exception:

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

When the nurse documents in narrative or source-oriented format about the patient's condition and the nursing care provided, it is appropriate for him to record:

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

A nurse enters a notation in a patient's medical record but then discovers that the notation was made in the wrong chart. The nurse correctly: