Deck 10: Documentation, Electronic Health Records, and Reporting

Question 1

Accurate documentation by the nurse is necessary since proper documentation:

A) is needed for proper reimbursement.
B) must be electronically generated.
C) does not involve e-mails or faxes.
D) is only legal if written by hand.

Answer 1

is needed for proper reimbursement.

Question 2

Nursing documentation is guided by:

A) the Nursing process
B) the North American Nursing Diagnosis Association (NANDA) diagnoses.
C) Nursing Interventions Classification.
D) Nursing Outcomes Classification

Answer 2

the Nursing process

Question 3

How should the nurse correct an error in charting?

A) remove the sheet with the error and replace it with a new sheet with the correct entry.
B) scribble out the error and rewrite the entry correctly.
C) draw a single line through the error, and then write "error" above or after the entry
D) leave the entry as is and tell the charge nurse.

Answer 3

draw a single line through the error, and then write "error" above or after the entry

Question 4

The nurse is preparing to administer medications to the patient. Prior to doing so, she/he compares the provider orders with the:

A) flow sheet
B) Kardex
C) MAR
D) admission summary

Question 5

The nurse is charting using paper nursing notes. The nurse is aware that:

A) attorneys are not allowed access to medical records during litigation.
B) when mistakes are made in documentation, the nurse should scribble out the entry.
C) only one nurse should document on a sheet so that it can be removed in case of error.
D) the medical record is the most reliable source of information in any legal action.

Question 6

The process of making a change-of-shift report (handoff):

A) is an uncommon occurrence of little importance.
B) occurs only at change of shift and only to oncoming nurses.
C) can lead to patient death if done incorrectly.
D) does not allow for collaboration or problem solving.

Question 7

The patient has fallen when trying to climb out of bed. The nurse:

A) needs to complete an incident report as a risk management document.
B) completes an incident report since it is a permanent part of the medical record.
C) must document that an incident report was completed in the medical record.
D) should say nothing about the incident in the medical record.

Question 8

The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:

A) allow only nurses that she knows and trusts to use her verification code.
B) not worry about mistakes since the information cannot be tracked.
C) never share her password with anyone.
D) be aware that the EHR is sophisticated and immune to failure.

Question 9

Paper records are being replaced by other forms of record keeping because:

A) paper is fragile and susceptible to damage.
B) paper records are always available to multiple people at a time.
C) paper records can be stored without difficulty and are easily retrievable.
D) paper records are permanent and last indefinitely.

Question 10

Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:

A) documents facts.
B) documents how he/she feels about the care being provided.
C) documents in a "block" fashion once per shift.
D) double documents as often as possible in order to not miss anything.

Question 11

Which of the following is true regarding nursing documentation?

A) Standards for documentation are established by a national commission.
B) Medical records should be accessible to everyone.
C) Documentation should not include the patient's diagnosis.
D) High-quality nursing documentation reflects the nursing process.

Question 12

The use of electronic health records:

A) improves patient health status.
B) requires a keyboard to enter data.
C) has not been shown to reduce medication errors.
D) requires increased storage space.

Question 13

The medical record:

A) serves as a major communication tool but is not a legal document.
B) cannot be used to assess quality of care issues.
C) is not used to determine reimbursement claims.
D) can be used as a tool for biomedical research and provide education.

Question 14

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:

A) admission summary.
B) discharge summary.
C) flow sheet.
D) Kardex.

Question 15

The nurse is charting using electronic documentation. With electronic documentation:

A) errors can be corrected and totally removed from the record in the screen view.
B) log-on access to the electronic record identifies the person charting.
C) each entry requires the nurse to sign her/his name and credentials.
D) documenting significant changes in the electronic record ends the nurse's responsibility.

Question 16

PIE, APIE, SOAP, and SOAPIE are:

A) chronologic.
B) examples of problem-oriented charting.
C) narrative charting.
D) forms of "charting by exception."

Question 17

If a verbal or phone order is necessary in an emergency, the order:

A) must be taken by an RN or LPN.
B) must be repeated verbatim to confirm accuracy.
C) documented as a written order.
D) does not need further verification by the provider.

Question 18

A type of charting that records only abnormal or significant data is:

A) PIE.
B) SOAP.
C) narrative.
D) charting by exception.

Question 19

The nurse is charting in the paper medical record. She should:

A) print his/her name since signatures are often not readable.
B) not document her credentials since everyone knows that she is a nurse.
C) skip a line, leaving a blank space, between entries so that it looks neater.
D) use black ink unless the facility allows a different color.

Question 20

The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient's medical history, the nurse may use the:

A) electronic medical record (EMR).
B) the computerized provider order entry (CPOE).
C) electronic health record (EHR).
D) American Recovery and Reinvestment Act.

Question 21

The nurse is charting using the DAR charting system. This form of charting requires documentation about: (Select all that apply.)

A) the patient problems.
B) subjective data.
C) any actions initiated.
D) objective data.
E) the patient's response to interventions.

Question 22

Expected nursing documentation includes: (Select all that apply.)

A) nursing assessment.
B) the care plan.
C) critique of the physician's care.
D) interventions.
E) patient responses to care.

Question 23

Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. Of the following, which are acceptable? (Select all that apply.)

A) Daily
B) QD
C) qod
D)0.X mg
E) X mg

Question 24

Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process. Use of standardized language: (Select all that apply.)

A) provides consistency.
B) improves communication among nurses while excluding non-nurses.
C) increases the visibility of nursing interventions.
D) enhances data collection.
E) supports adherence to care standards.

Question 25

The Health Insurance Portability and Accountability Act (HIPAA) mandates that health information can be shared: (Select all that apply.)

A) In order to provide treatment for the patient.
B) To determine billing and payment issues.
C) To enhance health care operations related to the patient.
D) In public areas such as the cafeteria or elevator.
E) Over the telephone with any family member