Exam 26: Documentation and Informatics

Which of the following nursing notations shows the greatest need for instruction regarding the need to document only objective client assessment data?

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care?

Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy?

To avoid legal risks and possible lack of confidentiality associated with computerized documentation,many programs currently have:

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

The nurse is preparing the information that will be provided to the staff on the next shift.Which of the following should the nurse include in the inter-shift report to nursing colleagues?

The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:

Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?

The nurse has made an error and is documenting such on the client's record and notes.The action that the nurse should take is to:

Related to Problem Oriented Medical Record (POMR)documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

The professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination,observation,conversation,or treatment:

The new staff nurse is having her documentation evaluated by the charge nurse.On review of her charting,the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

An incident report is to be completed because the client climbed over the side rails and fell to the floor.The correct reporting of an incident involves which of the following?

What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients.

Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care?

The client developed a slight hematoma on his left forearm.The nurse labels the problem as an infiltrated intravenous (IV)line.The nurse elevates the forearm.The client states,"My arm feels better." What is documented as the "R" in FOCUS charting?

Which of the following is evaluated as a legally appropriate notation?