Deck 5: Documentation

Question 1

A nursing instructor observes a student nurse documenting in the wrong patient's chart. The nursing instructor would intervene when observing the student nurse

A) Writing initials just above the incorrect entry.
B) Using a marker to blacken the incorrect entry.
C) Writing "mistaken entry" just above incorrect entry.
D) Marking a single horizontal line through the incorrect entry.

Answer 1

Using a marker to blacken the incorrect entry.

Question 2

A nursing instructor explains to students that the confidentiality of a patient's chart, the results of diagnostic procedures and consultations, and any notes they might write regarding the patient's health status is guaranteed by

A) The Joint Commission.
B) the Health Insurance Portability and Accountability Act (HIPAA).
C) the ethics committee.
D) the Nurse Practice Act (NPA).

Answer 2

the Health Insurance Portability and Accountability Act (HIPAA).

Question 3

When a patient complains of pain, a nurse assesses the pain level and administers pain medication. Using DAR charting, the nurse should chart these actions under

A) Data.
B) Action.
C) Response.
D) Assessment.

Answer 3

Action.

Question 4

A patient complains of feeling short of breath. His oxygen saturation level is 86%. When auscultating his lung sounds, a nurse notes wheezes and crackles throughout. The patient has a productive cough of thick green mucus. The nurse should chart these actions under the section of DAR charting that is called

A) Data.
B) Action.
C) Response.
D) Assessment.

Question 5

A nurse educates a nursing student about effective patient care. The nurse recognizes that additional instruction is needed when the nursing student states:

A) "For patient care to be effective, it must be delivered periodically."
B) "For patient care to be effective, it must be delivered continuously."
C) "For patient care to be effective, it must be evaluated continuously."
D) "For patient care to be effective, it must be delivered systematically."

Question 6

A nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states:

A) "The purpose of written documentation is to communicate pertinent data to the health-care team."
B) "The purpose of written documentation is to serve as a record of accountability for accreditation."
C) "The purpose of written documentation is to serve as a legal record for the health-care provider only."
D) "The purpose of written documentation is to serve as a record of accountability for quality assurance."

Question 7

A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n)

A) Emergency record.
B) Incident report.
C) Progress report.
D) Grievance report.

Question 8

A nurse is aware that the best method to ensure documentation accuracy is to consistently chart

A) At the completion of each shift.
B) Within 4 hours of providing care.
C) Immediately after care is provided.
D) Immediately before providing care.

Question 9

While documenting in a patient's chart, a nurse recognizes that

A) Documentation serves as a temporary part of the medical record.
B) Documentation is one of the least important tasks performed in nursing.
C) Documentation is the act of charting only abnormal information related to a patient.
D) Documentation is evidence of what transpired during an event requiring medical care.

Question 10

A nursing instructor is educating a class of student nurses about charting direct statements made by a patient. The best example of this would be

A) States, "He vomited everything he ate and drank yesterday."
B) States, "He is in excruciating pain. The pain is unrelieved by analgesics."
C) States, "The pain is getting worse. I don't know if I can stand it or not."
D) States, "His pain is getting worse and he doesn't know if he can stand it or not."

Question 11

A nursing instructor educates a class of nursing students about a common type of focus charting known as DAR. The nursing instructor teaches that the acronym DAR stands for

A) Data, Action, Response.
B) Data, Assessment, Revision.
C) Diagnosis, Action, Response.
D) Data, Assessment, Response.

Question 12

A nurse is educating a student nurse about documentation. The nurse recognizes that additional teaching is required when the student nurse states:

A) "Documentation serves as a temporary part of the medical record."
B) "Documentation is one of the most important tasks that I'll perform in nursing."
C) "Documentation is the act of charting pertinent information related to a patient."
D) "Documentation is evidence of what transpired during an event requiring medical care."

Question 13

A nursing instructor educates a class of nursing students about SOAPIER charting. The nursing instructor teaches that the acronym SOAPIER stands for

A) Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision.
B) Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results.
C) Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
D) Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision.

Question 14

While documenting in a patient's chart, a nurse realizes that it is the wrong patient's chart. The nurse should

A) Write over the incorrect letters.
B) Use correction fluid to blank out the mistaken entry.
C) Use correction tape to blank out the mistaken entry.
D) Write "mistaken entry" and his or her initials just above incorrect entry.

Question 15

A hospitalized patient tells a nurse that he wishes to take the original chart copy of his medical record home. The nurse's best response is

A) "You may not have it because it belongs to your physician."
B) "It is your medical record, and you are allowed to take it home."
C) "It is against hospital policy for you to look at your medical record."
D) "You are allowed to have a copy of your medical record to take home."

Question 16

A patient complains of left-sided chest pain radiating to the left shoulder. Using the SOAPIER method, a nurse should chart this complaint under the initial

A) S.
B) O.
C) A.
D) P.

Question 17

A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is:

A) "Average intake of clear liquid diet noted."
B) "Patient tolerates the clear liquid diet well."
C) "Patient swallowing clear liquids normally."
D) "No complaints of nausea while on clear liquid diet."

Question 18

The method of charting that provides a continual description of a patient's condition, complaints, problems, assessment findings, activities, treatments, and nursing care, along with the evaluations of effectiveness for each nursing intervention from admission through discharge, is known as

A) Charting by exception.
B) Focus charting.
C) Narrative charting.
D) SOAPIER (Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision) charting.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 19

A nurse teaches a student nurse about what type of occurrence requires completion of an incident report. The nurse recognizes that additional instruction is warranted when the student nurse states:

A) "If my patient falls out of a chair, I will complete an incident report."
B) "If I give the wrong medication to my patient, I will complete an incident report."
C) "If a visitor is injured while seeing my patient, I will complete an incident report."
D) "If my patient refuses to cooperate with physical therapy, I will complete an incident report."

Question 20

A patient appears anxious. The patient speaks quickly and paces the hospital halls. Using the SOAPIER method, a nurse should chart this finding under the initial

A) S.
B) O.
C) A.
D) P.

Question 21

The staff members at a hospital are preparing for a visit from The Joint Commission. The nursing supervisor explains to the staff that The Joint Commission does which of the following?

A) Acts as an insurance company by offering reimbursement to hospitals
B) Seeks to improve the safety and quality of care that health-care organizations provide to the public
C) Offers accreditation when a facility practices in a manner that meets The Joint Commission's standards
D) Sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance
E) Sets the standards by which the quality of health care is managed nationally and internationally

Question 22

A nursing instructor teaches a class of nursing students that the purpose of written documentation is which of the following?

A) To communicate pertinent data to the health-care team
B) To serve as a record of accountability for accreditation
C) To serve as a legal record for the health-care provider only
D) To serve as a record of accountability for quality assurance and reimbursement purposes
E) To provide a permanent record of medical and nursing diagnoses

Question 23

A nursing instructor teaches a class of students that a source-oriented medical record may include which of the following labeled section tabs?

A) Nurse's notes
B) Progress notes
C) Graphic data
D) Physician's orders
E) Rehabilitation therapy

Question 24

A nursing instructor teaches a class of students that a problem-oriented medical record includes which of the following sections?

A) Database
B) Problem list
C) Plan of care
D) Progress notes
E) Incident reports

Question 25

A hospital's risk-management team provides the nursing staff with an in-service about incident reports. The in-service should include which of the following pieces of information?

A) An incident report always involves the patient.
B) Incident reports are part of the patient's medical record.
C) A medication error should be documented on an incident report.
D) A patient, visitor, or employee injury should be documented on an incident report.
E) An incident report is used to document out-of-the-ordinary things that happen in a health-care facility.

Question 26

Because security and confidentiality of medical records are such a major concern, all employees who need access to computerized patient records are assigned a secure ____________________ that must be changed at regular intervals.

Question 27

A nursing instructor is educating a group of student nurses about the Health Insurance Portability and Accountability Act (HIPAA). The nursing instructor teaches that HIPAA does which of the following?

A) Guarantees a patient the right to view and obtain a copy of his or her medical record
B) Guarantees a patient the right to take the original medical chart
C) Asks a patient to specify who can obtain his or her personal health data
D) Ensures the right of a patient to amend his or her own health information
E) Requires hospitals to disclose the way in which a patient's health data will be used

Question 28

A nursing instructor explains that one disadvantage to using ____________________ patient records is that the systems can be hacked into illegally, putting patient confidentiality at risk.

Question 29

Many facilities use a quick reference report form known as a(n) ____________________ that places the physician's orders and the nursing orders for each patient in one location, on a single page where it can be retrieved or referred to quickly without having to go through an entire patient chart or medical record.

Question 30

A form of documentation developed for each patient known as a(n) ____________________ serves to provide a daily plan of action that communicates a patient's problems, what interventions are to be performed for each problem, and the effectiveness of each intervention.

Question 31

To protect a patient's ____________________ when faxing medical records, a nurse should telephone the intended recipient to inform him or her of the impending fax to ensure that the intended recipient is present.