Deck 3: Documentation

Question 1

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

Answer 1

Chart consecutively

Question 2

What regulates standards for long-term care documentation?

A) OBRA
B) Title XXII
C) Nursing diagnoses
D) The care plan

Answer 2

OBRA

Question 3

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

Answer 3

To evaluate care results against accepted standards

Question 4

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

Question 5

What makes home health care documentation unique?

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 6

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

Question 7

What is the documentation format that uses the acronym SOAPE?

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

Question 8

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.

Question 9

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

Question 10

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

Question 11

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

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:

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

Question 13

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.

Question 14

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

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

Question 15

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

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 nursing diagnoses identified?

A) Physician
B) Registered nurse
C) Nursing assistant
D) Licensed practical nurse/licensed vocational nurse

Question 17

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

Question 18

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

Question 19

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

A) Patient
B) Physician
C) Institution
D) State

Question 20

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

Question 21

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

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

Question 22

The best defense against malpractice claims associated with nursing care is accurate _____________.

Question 23

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

Question 24

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

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 25

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

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 26

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

Question 27

What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.)

A) Incorrectly recording the time of an event
B) Failing to record verbal orders
C) Charting events in advance
D) Documenting an incorrect date
E) Marking out and initialing charting errors

Question 28

What are some problems associated with electronic (or computerized) charting? (Select all that apply.)

A) Security
B) Expense of training staff
C) Legibility
D) Easy retrieval
E) New terminology

Question 29

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

Question 30

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