Deck 5: Documentation

Question 1

The nursing instructor is reviewing the different types of charting methods with the class.Which should the instructor explain for the acronym SOAPIER?

A)Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision
B)Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results
C)Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision
D)Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision

Answer 1

Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision

Question 2

The nurse completes documentation on an electronic medical record.What should the nurse do next?

A)Log out of the system.
B)Discard the report form.
C)Prepare to give the report to the next nurse.
D)Answer call lights and provide medication.

Answer 2

Log out of the system.

Question 3

A health-care facility uses narrative charting.What should the nurse remember when following this documentation approach?

A)It tells the client's story.
B)It focuses on data, action, and response.
C)It is the least thorough documentation method.
D)It is the least time-consuming documentation method.

Answer 3

It tells the client's story.

Question 4

A resident is being admitted to the skilled nursing facility.Which documentation is required to be completed for this client?

A)Kardex
B)Care plan
C)Advance directive
D)Minimum data set

Question 5

Information about the Health Insurance Portability and Accountability Act (HIPAA)is being prepared for a group of new nurses to review during orientation.Which should be emphasized about this act? Select all that apply.

A)HIPAA guarantees a client the right to view and obtain a copy of his or her medical record.
B)HIPAA guarantees a client the right to take the original medical chart.
C)HIPAA asks a client to specify who can obtain personal health data.
D)HIPAA ensures the right of a client to amend personal health information.
E)HIPAA requires hospitals to disclose the way in which a client's health data will be used.

Question 6

A client received a dose of intravenous pain medication before change of shift.After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest.Who is most liable for this situation?

A)The nurse who gave the first dose of medication
B)The nurse who gave the second dose of medication
C)The health-care provider who prescribed the medication
D)The person who called the nurse away before documenting the medication

Question 7

The nurse notices that there is no room at the end of a written note to sign the note.What should the nurse do?

A)Initial each line of the note.
B)Initial at the end of the note.
C)Draw a line through the space on the next line and sign at the end.
D)Draw a parenthesis around the entire note and sign and credential it in the margin.

Question 8

The nurse receives a login and password to access the electronic medical record.Where should the nurse store this information?

A)Tape it to the inside of the locker door.
B)Tape it to the underside of the keyboard.
C)Place it in the pocket protector used for care.
D)Place it in the wallet that is locked up during the shift.

Question 9

The director of a home care agency is scheduling staff to make home visits.Which staff member should visit a client newly admitted to the agency for care?

A)Agency director
B)Registered nurse
C)Nursing assistant
D)Licensed practical/vocational nurse

Question 10

The staff members at a hospital are preparing for a visit from The Joint Commission (TJC).Which should be explained to the staff about the purpose of this visit? Select all that apply.

A)TJC acts as an insurance company by offering reimbursement to hospitals.
B)TJC seeks to improve the safety and quality of care that health-care organizations provide to the public.
C)TJC offers accreditation when a facility practices in a manner that meets TJC standards.
D)TJC sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance.
E)TJC sets the standards by which the quality of health care is managed nationally and internationally.

Question 11

The nursing instructor is reviewing documentation with a group of students.Which should the instructor include as the purpose of written documentation? Select all that apply.

A)Communicate pertinent data to the health-care team
B)Serve as a record of accountability for accreditation
C)Serve as a legal record for the health-care provider only
D)Serve as a record of accountability for quality assurance and reimbursement purposes
E)Provide a permanent record of medical and nursing diagnoses

Question 12

The nurse discovers a client lying on the floor.Which should the nurse write when completing an incident report?

A)"Client fell out of bed onto the floor."
B)"Heard client fall from the bed to the floor."
C)"Client accidentally fell out of bed onto the floor."
D)"Found client lying face down on the floor beside the bed."

Question 13

The nurse reviews pertinent laboratory data and assesses the response to pain medication.Where should the nurse write this information until able to document it in the medical record?

A)Report form
B)Bedside clipboard
C)Intake and output record
D)Medication administration record

Question 14

A health-care organization is considering focus charting.Which categories are commonly documented using this approach?

A)Data, action, response
B)Abnormal findings and checklist
C)Problem, intervention, evaluation
D)Subjective, objective, assessment, plan

Question 15

While documenting in a client's chart, the nurse realizes that it is the wrong chart.What should the nurse do?

A)Write over the incorrect letters.
B)Use correction fluid to blank out the mistaken entry.
C)Use correction tape to blank out the mistaken entry.
D)Write "mistaken entry" and place initials just above incorrect entry.

Question 16

The nursing instructor is asked to prepare an educational program on incidents that have occurred on a specific care area.Which is the most cost-effective approach for the instructor to collect information to support the educational program?

A)Complete a database search through the electronic medical record.
B)Meet with risk management to review incident reports for the care area.
C)Ask the nurse manager to provide specific data regarding client incidents.
D)Access a quality assurance website to obtain information about common incidents.

Question 17

The nurse uses a cheat sheet to jot down pertinent client data while providing care.What should the nurse do with the sheet after documenting all client care?

A)Shred the paper.
B)Throw it in the trash.
C)Keep the paper for use the next day.
D)Give the paper to the next nurse during hand off communication.

Question 18

A hospital's risk-management team provides the nursing staff with an in-service about incident reports.Which information should be included? Select all that apply.

A)An incident report always involves the client.
B)Incident reports are part of the client's medical record.
C)A medication error should be documented on an incident report.
D)A client, visitor, or employee injury should be documented on an incident report.
E)An incident report is used to document out-of-the-ordinary things that happen in a health-care facility.

Question 19

The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client.Where should the nurse locate this information?

A)The clipboard
B)The Kardex
C)The medical record
D)The medication administration record

Question 20

The nurse is preparing to document care provided in the client's electronic medical record.Which should the nurse keep in mind when entering the data?

A)Avoid using abbreviations within the note.
B)Document "not observed" to prevent any blank lines.
C)Copy and paste pertinent data from the previous note.
D)Quantify statements by using the words "average" or "normal."

Question 21

The nursing instructor teaches students about source-oriented medical records.Which labeled tabs should the instructor emphasize? Select all that apply.

A)Nurse's notes
B)Care plan
C)Graphic data
D)Physician's orders
E)Rehabilitation therapy

Question 22

The nursing instructor is reviewing documents with a group of students.Which parts of the problem-oriented medical record should be discussed? Select all that apply.

A)Database
B)Problem list
C)Plan of care
D)Progress notes
E)Incident reports