Question 1

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

Accepted Answer

A)  Problem list 
B)  Nursing orders 
C)  Nursing diagnoses 
D)  Evaluation 
A)  Problem list 
B)  Nursing orders 
C)  Nursing diagnoses 
D)  Evaluation C

Question 2

Documentation using the DARE format (Data, Action, Response, Education) includes elements of the __________ charting system.

Accepted Answer

focused
Focused charting uses the acronym DARE to direct and formalize charting.

Question 3

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?

Accepted Answer

A)  Planning 
B)  Assessment 
C)  Implementation 
D)  Patient teaching 
A)  Planning 
B)  Assessment 
C)  Implementation 
D)  Patient teaching B

Question 4

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?

Accepted Answer

A)  Quality assurance 
B)  Resource assessment 
C)  Quality improvement 
D)  Diagnosis-related groups 
A)  Quality assurance 
B)  Resource assessment 
C)  Quality improvement 
D)  Diagnosis-related groups

Question 5

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

Accepted Answer

A)  Scratch out the error 
B)  Apply correction fluid 
C)  Erase the error completely 
D)  Draw a single line through the error 
A)  Scratch out the error 
B)  Apply correction fluid 
C)  Erase the error completely 
D)  Draw a single line through the error

Question 6

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

Accepted Answer

A)  Assessment 
B)  Planning 
C)  Implementation 
D)  Evaluation 
A)  Assessment 
B)  Planning 
C)  Implementation 
D)  Evaluation

Question 7

A nurse is receiving a telephone order from a physician. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the correct order of this method?
A) Read back
B) Background
C) Recommendation
D) Situation
E) Assessment

Accepted Answer

D, B, E, C, A
SBAR (Situation, Backgroun

Question 8

What is the purpose of QA (quality assurance)?

Accepted Answer

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 
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

Question 9

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

Accepted Answer

A)  Include speculation 
B)  Chart consecutively 
C)  Leave blank spaces 
D)  Include retaliatory comments 
A)  Include speculation 
B)  Chart consecutively 
C)  Leave blank spaces 
D)  Include retaliatory comments

Question 10

What are the basic purposes of written patient records? (Select all that apply.)

Accepted Answer

A)  Teaching 
B)  Legal record of care 
C)  Written communication 
D)  Research and data collection 
E)  Permanent record for accountability
F) Temporary record of hospitalization 
A)  Teaching 
B)  Legal record of care 
C)  Written communication 
D)  Research and data collection 
E)  Permanent record for accountability
F) Temporary record of hospitalization

Question 11

What makes home health care documentation unique?

Accepted Answer

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. 
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.

Question 12

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:

Accepted Answer

A)  nursing order. 
B)  Kardex. 
C)  nursing care plan. 
D)  critical pathway. 
A)  nursing order. 
B)  Kardex. 
C)  nursing care plan. 
D)  critical pathway.

Question 13

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

Accepted Answer

A)  Subjective data 
B)  Focus chart 
C)  Incident report 
D)  Nursing assessment 
A)  Subjective data 
B)  Focus chart 
C)  Incident report 
D)  Nursing assessment

Question 14

When documenting an incident in the nurse's notes, what should the nurse include? (Select all that apply.)

Accepted Answer

A)  Description of injury, including diagrams of injury placement 
B)  Date, time, and location of incident 
C)  Name of physician and family members notified 
D)  Chronologic order of events of the incident 
E)  Confirmation that an incident report was initiated 
A)  Description of injury, including diagrams of injury placement 
B)  Date, time, and location of incident 
C)  Name of physician and family members notified 
D)  Chronologic order of events of the incident 
E)  Confirmation that an incident report was initiated

Question 15

Why is documentation especially significant in managed care?

Accepted Answer

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. 
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.

Question 16

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

Accepted Answer

A)  Quality assurance 
B)  Incident reporting 
C)  OBRA 
D)  Peer review 
A)  Quality assurance 
B)  Incident reporting 
C)  OBRA 
D)  Peer review

Question 17

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

Accepted Answer

A)  SOAP 
B)  Block 
C)  CBE 
D)  Focus 
A)  SOAP 
B)  Block 
C)  CBE 
D)  Focus

Question 18

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

Accepted Answer

quality assurance
quality assessment
qua

Question 19

What is the documentation format that uses the acronym SOAPE?

Accepted Answer

A)  Problem-oriented 
B)  Focused 
C)  Traditional 
D)  Crisis 
A)  Problem-oriented 
B)  Focused 
C)  Traditional 
D)  Crisis

Question 20

What should a medical record provide for all health care providers? (Select all that apply.)

Accepted Answer

A)  Care given to the patient 
B)  Care planned for the patient 
C)  A patient's nursing problems 
D)  A patient's medical problems 
E)  Details about any incident reports
F) The patient's response to treatment 
A)  Care given to the patient 
B)  Care planned for the patient 
C)  A patient's nursing problems 
D)  A patient's medical problems 
E)  Details about any incident reports
F) The patient's response to treatment

Exam 3: Documentation

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

Documentation using the DARE format (Data, Action, Response, Education) includes elements of the __________ charting system.

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?

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?

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

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

What is the purpose of QA (quality assurance)?

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

What are the basic purposes of written patient records? (Select all that apply.)

What makes home health care documentation unique?

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

When documenting an incident in the nurse's notes, what should the nurse include? (Select all that apply.)

Why is documentation especially significant in managed care?

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

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

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

What is the documentation format that uses the acronym SOAPE?

What should a medical record provide for all health care providers? (Select all that apply.)

Evolution of Nursing

Legal and Ethical Aspects of Nursing

Communication

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patient’s Environment

Safety

Vital Signs

Physical Assessment

Admission, Transfer, and Discharge

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Care of Patients Experiencing Urgent Alterations in Health

Complementary and Alternative Therapies

Pain Management, Comfort, Rest, and Sleep

Nutritional Concepts and Related Therapies

Fluids and Electrolytes

Mathematics and Medication Administration

Care of Patients with Alterations in Health

Life Span Development

Loss, Grief, Dying, and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, Newborn, and Family with Special Needs

Health Promotion for the Infant, Child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child with a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient with a Psychiatric Disorder

Care of the Patient with an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Introduction to Anatomy and Physiology

Care of the Surgical Patient

Care of the Patient with an Integumentary Disorder

Care of the Patient with a Musculoskeletal Disorder

Care of the Patient with a Gastrointestinal Disorder

Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Care of the Patient with a Blood or Lymphatic Disorder

Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder

Care of the Patient with a Respiratory Disorder

Care of the Patient with a Urinary Disorder

Care of the Patient with an Endocrine Disorder

Care of the Patient with a Reproductive Disorder

Care of the Patient with a Sensory Disorder

Care of the Patient with a Neurologic Disorder

Care of the Patient with an Immune Disorder

Care of the Patient with HIV/AIDS

Care of the Patient with Cancer

Professional Roles and Leadership

Filters

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____.