Question 1

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.

Question 2

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

Accepted Answer

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 3

What is the documentation format that uses the acronym SOAPE?

Accepted Answer

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

Question 4

What regulates standards for long-term care documentation?

Accepted Answer

A) OBRA 
B) Title XXII 
C) Patient problems 
D) The care plan

Question 5

What does documentation of type of care,time of care,and signature of the person prove?

Accepted Answer

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 6

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 patient problem identified?

Accepted Answer

A) Health care provider 
B) Registered nurse 
C) Unlicensed assistive personnel 
D) Licensed practical nurse/licensed vocational nurse

Question 7

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

Question 8

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

Exam 3: Documentation