Question 1

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

Accepted Answer

Logging off closes the computer file that was opened with the nurse's password.Any other data entry will require that person to sign on with their password.

Question 2

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?
A)SOAP
B)Block
C)CBE
D)Focus

Accepted Answer

Charting additional treatments done,changes in a patient's condition,and new concerns during the shift is charting by exception (CBE).

Question 3

What is the process used to appraise the practice of an individual nurse known as?
A)Quality assurance
B)Incident reporting
C)OBRA
D)Peer review

Accepted Answer

Peer review is an in-house department study that may appraise the nursing practice of individual nurses.

Question 4

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?
A)Assessment
B)Planning
C)Implementation
D)Evaluation

Accepted Answer

Documentation is part of the implementation phase of the nursing process.

Question 5

What should the nurse be sure to do when documenting in a patient's chart?
A)Include speculation.
B)Chart consecutively.
C)Leave blank spaces.
D)Include retaliatory comments.

Accepted Answer

A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals.The nurse should not leave blank spaces in the nurse's notes.The nurse should be certain the entry is factual and not speculate or guess.The nurse should chart consecutively,line by line.

Question 6

What will the nurse implement when an error is made when documenting in a patient's chart?
A)Scratch out the error.
B)Apply correction fluid.
C)Erase the error completely.
D)Draw a single line through the error.

Accepted Answer

A nurse should not erase,apply correction fluid,or scratch out errors made while recording in a patient's chart.Instead,the nurse should draw a single line through the error,write the word "error" above it,and sign her name or initials.

Question 7

What makes home health care documentation unique?
A)Some charting is retained at the hospital.
B)The health care provider's office needs separate charting.
C)Different health care providers need access.
D)The health care provider is the pivotal person in the charting.

Accepted Answer

Home health care documentation has unique problems because of the need for different health care workers to access the medical record.

Question 8

What regulates standards for long-term care documentation?
A)OBRA
B)Title XXII
C)Patient problems
D)The care plan

Accepted Answer

OBRA (Omnibus Budget Reconciliation Act)was a significant Medicare and Medicaid legislation for long-term health care documentation.

Question 9

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?
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.

Accepted Answer

The nurse should not read the patient's medical record unless there is a clinical reason for doing so.

Question 10

What does the nurse use as a basis for documentation in focus charting?
A)Problem list
B)Nursing orders
C)Patient problems
D)Evaluation

Accepted Answer

In focus charting,instead of using the problem list,modified patient problems are used as an index for nursing documentation.

Question 11

What is the system that classifies patients by age,diagnosis,and surgical procedure,and produces 300 different categories used for predicting the use of hospital resources?
A)Quality assurance
B)Resource assessment
C)Quality improvement
D)Diagnosis-related groups

Accepted Answer

Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs),which is a system that classifies patients by age,diagnosis,and surgical procedure,producing 300 different categories used in predicting the use of hospital resources,including length of stay.

Question 12

Who is the legal owner of the patient's medical record?
A)Patient
B)Health care provider
C)Institution
D)State

Accepted Answer

Ownership of a medical record belongs to the institution in the case of a hospitalized patient,or the health care provider in the case of private office visits.

Question 13

What form explains the lapse when events are not consistent with facility or national standards of expected care?
A)Subjective data
B)Focus chart
C)Incident report
D)Nursing assessment

Accepted Answer

An incident report is completed when patient care was not consistent with facility or national standards.The form explains the event,time,extent of injury,and who was notified.

Question 14

What is the purpose of QA (quality assurance)?
A)To screen employment applications
B)To evaluate care results against accepted standards
C)To conduct in-services for "quality documentation"
D)To report deviation from standards to the state health department

Accepted Answer

QA is an in-house department that evaluates care services and results against accepted standards.

Question 15

Why is documentation especially significant in managed care?
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.

Accepted Answer

Cost reimbursement rates by government plans (Medicare,Medicaid)are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age,diagnosis,surgical procedure,and other information with hundreds of different categories to predict the use of hospital resources,including length of stay,resulting in a fixed payment amount.

Question 16

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified?
A)Health care provider
B)Registered nurse
C)Unlicensed assistive personnel
D)Licensed practical nurse/licensed vocational nurse

Accepted Answer

The registered nurse (RN)has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified.

Question 17

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:
A)nursing order.
B)Kardex.
C)nursing care plan.
D)critical pathway.

Accepted Answer

Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.

Question 18

What does documentation of type of care,time of care,and signature of the person prove?
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.

Accepted Answer

Documenting type of care,time of care,and signature of the person results in recording the interventions that are implemented to meet the patient's needs.Many charting entries include health care provider's visits,presence of family,or interventions by other departments.Patient response to some interventions is not always positive.

Question 19

What is the documentation format that uses the acronym SOAPE?
A)Problem-oriented
B)Focused
C)Traditional
D)Crisis

Accepted Answer

The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems.

Question 20

A nurse is using the data,action,response,education (DARE)system of charting,and is completing the data portion.What data are the nurse's focus?
A)Planning
B)Assessment
C)Implementation
D)Patient teaching

Accepted Answer

DARE is the acronym for four different aspects of charting using the focus format.Data (D)is both subjective and objective and is equivalent to the assessment step of the nursing process.Action (A)is a combination of planning and implementation.Response (R)of the patient is the same as evaluation of effectiveness.Some facilities include education/patient teaching (E).

Quiz 3: Documentation

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

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

What is the process used to appraise the practice of an individual nurse known as?

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

What should the nurse be sure to do when documenting in a patient's chart?

What will the nurse implement when an error is made when documenting in a patient's chart?

What makes home health care documentation unique?

What regulates standards for long-term care documentation?

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

What does the nurse use as a basis for documentation in focus charting?

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

Who is the legal owner of the patient's medical record?

What form explains the lapse when events are not consistent with facility or national standards of expected care?

What is the purpose of QA (quality assurance) ?

Why is documentation especially significant in managed care?

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified?

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

What does documentation of type of care,time of care,and signature of the person prove?

What is the documentation format that uses the acronym SOAPE?

A nurse is using the data,action,response,education (DARE) system of charting,and is completing the data portion.What data are the nurse's focus?