Question 1

When events are not consistent with facility or national standards of expected care,the form that explains the lapse is the:
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 2

The process used to appraise the practice of an individual nurse is called:
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 3

When focus charting,what does the nurse use as a basis for documentation?
A) Problem list
B) Nursing orders
C) Nursing diagnoses
D) Evaluation

Accepted Answer

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

Question 4

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 5

A system that classifies patients by age,diagnosis,and surgical procedure and produces 300 different categories used for predicting the use of hospital resources is known as:
A) quality assurance.
B) resource assessment.
C) quality improvement.
D) diagnosis-related groups.

Accepted Answer

Cost reimbursement rates by the 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 6

Standards for long-term care documentation are regulated by:
A) OBRa.
B) Title XXII.
C) nursing diagnoses.
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 7

When using the data,action,response,education (DARE)system of charting,the data portion focuses on:
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).

Question 8

In managed care,documentation is especially significant because:
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

Institutions are reimbursed only for patient care that is documented.

Question 9

Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:
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

Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the nursing diagnoses identified?
A) Physician
B) Registered nurse
C) Nursing assistant
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 nursing diagnoses identified.

Question 11

If the nurse makes an error while documenting in a patient's chart,the nurse should:
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 12

When documenting in a patient's chart,the nurse should:
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 13

When the nurse charts only additional treatments done,changes in patient condition,and new concerns,the system of documentation is:
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 14

Documentation is necessary for the evaluation of patient care and is an integral part of the nursing process phase of:
A) assessment.
B) planning.
C) implementation.
D) evaluation.

Accepted Answer

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

Question 15

The nurse knows that for a hospitalized patient,the legal owner of the patient's medical record is the:
A) patient.
B) physician.
C) institution.
D) state.

Accepted Answer

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

Question 16

The documentation format that uses the acronym SOAPE is:
A) problem-oriented.
B) focused.
C) traditional.
D) crisis.

Accepted Answer

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

Question 17

Home health care documentation is unique because:
A) some charting is retained at the hospital.
B) the physician's office needs separate charting.
C) different health care providers need access.
D) the physician 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 18

Documentation of type of care,time of care,and signature of the person who is documenting proves that:
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

This information results in recording the interventions that are implemented to meet the patient's needs.Many charting entries include doctor's visits,presence of family,or interventions by other departments.Patient response to some interventions is not always positive.

Question 19

When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type,it 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 20

The purpose of QA (quality assurance)is to:
A) screen employment applications.
B) evaluate care results against accepted standards.
C) conduct in-services for "quality documentation."
D) 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.

Quiz 7: Documentation

When events are not consistent with facility or national standards of expected care,the form that explains the lapse is the:

The process used to appraise the practice of an individual nurse is called:

When focus charting,what does the nurse use as a basis for 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?

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

Standards for long-term care documentation are regulated by:

When using the data,action,response,education (DARE) system of charting,the data portion focuses on:

In managed care,documentation is especially significant because:

Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:

Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the nursing diagnoses identified?

If the nurse makes an error while documenting in a patient's chart,the nurse should:

When documenting in a patient's chart,the nurse should:

When the nurse charts only additional treatments done,changes in patient condition,and new concerns,the system of documentation is:

Documentation is necessary for the evaluation of patient care and is an integral part of the nursing process phase of:

The nurse knows that for a hospitalized patient,the legal owner of the patient's medical record is the:

The documentation format that uses the acronym SOAPE is:

Home health care documentation is unique because:

Documentation of type of care,time of care,and signature of the person who is documenting proves that:

When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type,it is known as a:

The purpose of QA (quality assurance) is to: