Chapter 7 - Documentation, Nur 101

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Chapter 7 - Documentation, Nur 101
From Foundations of Nursing by Christensen and Kockrow, pages 138-157

  
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  • 1. 
    Which of the following does not refer to the process of adding written information to a health care record?
    • A. 

      Recording

    • B. 

      Charting

    • C. 

      Data entry

    • D. 

      Documenting


  • 2. 
    Which of the following statements about documenting is not true?
    • A. 

      Involves recording the interventions carried out to meet the patient's needs.

    • B. 

      Done in a proper way, it reflect the nursing process.

    • C. 

      Necessary to prove that nursing work was done.

    • D. 

      Nursing documentation can be accepted in both verbal and written form


  • 3. 
    Which of the following are basic purposes  for an accurate and complete written patient records? Select all that apply
    • A. 

      Sometimes used by government agencies to evaluate patient care

    • B. 

      It is a permanent record for accountability

    • C. 

      It is a legal record of care

    • D. 

      They are perfect sources for business and marketing

    • E. 

      Can be used for research, teaching and data collection


  • 4. 
    This is the main basis for cost reimbursement rates by government plans
    • A. 

      Critical pathway

    • B. 

      Minimum data sheet

    • C. 

      Diagnoses related groups

    • D. 

      Patient expense documentation


  • 5. 
    Which of the following statements are true regarding basic rules for documentation. Select all that apply.
    • A. 

      Use direct quotes for objective assessments

    • B. 

      If a charting error is made, draw one line through the faulty information

    • C. 

      Chart only your own care even when someone else calls you for a late entry.

    • D. 

      Chart after care is provided, as soon as possible, and as often as needed

    • E. 

      Sign each block of charting with full legal initials and title


  • 6. 
    Based upon the legal guidelines for documentation, which of the following corrective action is incorrect?
    • A. 

      Never erase entries or use correction fluid. Never right with a pencil.

    • B. 

      Do not record "physician made error".

    • C. 

      Be certain that entry is factual even when opinions are used

    • D. 

      While logged into the computer, do not leave terminal unattended even during an emergency.


  • 7. 
    Which of the following statements about common forms of inadequate documentation should not be included?
    • A. 

      Not charting correct time when events occurred

    • B. 

      Failing to record verbal orders or failing to have them signed

    • C. 

      Documentation only in hand written format even when EMR is mandated

    • D. 

      Charting actions in advance to save time

    • E. 

      Documenting incorrect data


  • 8. 
    What kind of documentation is the following?                                                                                              0800-1300 0 45, pain scale 0/10, hand and leg strong to right, weak to left. Skin pink, warm and dry, turgor good, incision to Rt. anterior chest wall erythema or edema ...................Jane Night, LPN.                                                                             
    • A. 

      Kardex

    • B. 

      Narrative

    • C. 

      Nurse's Notes

    • D. 

      Shift report


  • 9. 
    Which of the following practices could lead to malpractice? Select all that apply
    • A. 

      Charting interventions in advance to save time

    • B. 

      Documenting incorrect data

    • C. 

      Not charting the correct time when events took place

    • D. 

      Deleting incorrect entries and crossing them out with a horizontal line.

    • E. 

      Not recording verbal orders or not having them signed.


  • 10. 
    Charting that is divided into sections or blocks. Emphasis is placed on specific sections, or sheets of information. It also uses graphics and narrative charting
    • A. 

      Traditional Chart

    • B. 

      Problem-oriented medical record

    • C. 

      Standard form

    • D. 

      Kardex


  • 11. 
    Which of the following is a typical section of a traditional chart? Select all that apply
    • A. 

      Admission sheet and physician's orders

    • B. 

      Progress notes and nurse's admission information

    • C. 

      History and Physical Examination Data

    • D. 

      Medical Administration Record

    • E. 

      Care plan and nurse's notes


  • 12. 
    Which of the following is considered a traditional charting?
    • A. 

      Narrative

    • B. 

      Problem Oriented Medical Record

    • C. 

      SOAPE

    • D. 

      DARE


  • 13. 
     What is the difference between Traditional and Problem Oriented medical Record charting?
    • A. 

      Traditional uses an abbreviated story form. POMR uses an outline form

    • B. 

      Traditional uses SOAPE charting. Problems oriented medical record uses narrative charting

    • C. 

      Traditional uses blocks. POMR uses sections.

    • D. 

      Traditional focuses on interventions. POMR focuses on interventions.


  • 14. 
    Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply.
    • A. 

      Database

    • B. 

      Problem list

    • C. 

      Care plan

    • D. 

      Physical examination and diagnostic tests

    • E. 

      Referral form


  • 15. 
    Active, inactive potential and resolved problems that serve as the index for charting documentation
    • A. 

      Problem assessments

    • B. 

      Problem List

    • C. 

      Database

    • D. 

      Traditional Chart


  • 16. 
    Match the part of a specific type of documentation with its definition or description on the right
    • A. Subjective
    • A.
    • B. Objective
    • B.
    • C. Assessment
    • C.
    • D. Plan
    • D.
    • E. Intervention
    • E.
    • F. Evaluation
    • F.
    • G. Revision
    • G.

  • 17. 
    In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included? 
    • A. 

      It is not mentioned in this kind of documentation

    • B. 

      Included in the notations under PLANNING

    • C. 

      Included under assessment

    • D. 

      It belongs to another format


  • 18. 
    In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?
    • A. 

      REVISIONS belong to another format of documentation

    • B. 

      REVISIONS are not part of this documentation

    • C. 

      REVISIONS are noted in the EVALUATION section

    • D. 

      REGISIONS are noted in the ASSESSMENT section


  • 19. 
    Which of the following statements about FOCUS CHARTING is incorrect?
    • A. 

      Uses the nursing process and the more positive concept of patient needs

    • B. 

      Focus is sometimes a current patient concern or behavior.

    • C. 

      Focus is sometimes a significant changes in patient status or behavior or a significant event in the patient's therapy.

    • D. 

      Focus can be a medical diagnosis


  • 20. 
    In the DARE format of documentation, match the elements of the documentation with the corresponding situation on the right.
    • A. D
    • A.
    • B. A
    • B.
    • C. R
    • C.
    • D. E
    • D.

  • 21. 
    Which of the following statements regarding the DARE format of documentation are correct? Select all that apply
    • A. 

      Data, action, response and evaluation, education and patient teaching

    • B. 

      Data is both subjective and objective

    • C. 

      Action combines planning and implementation

    • D. 

      You need to use all the DARE steps each time you make notes on a particular focus

    • E. 

      Response is the same as evaluation and effectiveness

    • F. 

      Some facilities include education or patient teaching


  • 22. 
    There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming  and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with? 
    • A. 

      CBE

    • B. 

      DOA

    • C. 

      ABC

    • D. 

      APIE


  • 23. 
    Which of the following formats is included under Charting be exception? Select all that apply.
    • A. 

      PIE

    • B. 

      SOAPE

    • C. 

      SOAPIER

    • D. 

      APIE


  • 24. 
    What is the essential difference between PIE and SOAPE formats?
    • A. 

      PIE is from a nursing process. SOAPE is from a medical model

    • B. 

      PIE is from a medical model. SOAPE is from a nursing process

    • C. 

      PIE and SOAPE are both used for charting by exception

    • D. 

      PIE and SOAPE both emerge from the nursing process


  • 25. 
    What kind of notes are taken when charting by exception? Select all that apply.
    • A. 

      Additional treatments done or planned treatments withheld

    • B. 

      Standing orders and physical history

    • C. 

      New Concerns

    • D. 

      Changes in patient condition


  • 26. 
    In charting by exception, what happens after the patient's problem is resolved?
    • A. 

      It needs to be a part of the SOAPE documentation

    • B. 

      It needs to be explained to the next shift

    • C. 

      It is no longer covered by daily documentation

    • D. 

      It needs to be transferred to a permanent record


  • 27. 
    APIE is a variation of the PIE documentation. Match of the element of the documentation on the left with an example on the right
    • A. A
    • A.
    • B. P
    • B.
    • C. I
    • C.
    • D. E
    • D.

  • 28. 
    Which of the following are considered examples of record keeping forms? Select all that apply.
    • A. 

      Kardex or Rand

    • B. 

      Nursing Care Plan

    • C. 

      Incident Reports

    • D. 

      24-hour patient care and acuity charting

    • E. 

      Discharge summary


  • 29. 
    When is it unnecessary to chart a narrative note? Select all that apply.
    • A. 

      Each time you give a medication

    • B. 

      Each time a bath is given

    • C. 

      Each time a decubitus ulcer changes in appearance

    • D. 

      Each time you assess vital signs


  • 30. 
    A system used to consolidate patient orders and care needs in a centralized, concise way.  
    • A. 

      Incident Reports

    • B. 

      Kardex or Rand System

    • C. 

      Intervention Guidelines

    • D. 

      Nursing Care plan


  • 31. 
    Match the method of recording on the left with an example of documentation type on the right 
    • A. Traditional
    • A.
    • B. Problem Oriented Medical Record
    • B.
    • C. Focus Charting Format
    • C.
    • D. Charting by exception
    • D.
    • E. Record keeping forms
    • E.

  • 32. 
    Preprinted guidelines used to care for patients with similar health problems.
    • A. 

      Nursing Care Plan

    • B. 

      Kardex

    • C. 

      Common illness index

    • D. 

      Health intervention reference


  • 33. 
    Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation
    • A. 

      Standardized nursing care plans

    • B. 

      Plans written in nursing notes

    • C. 

      Narrative planning

    • D. 

      Kardex or Rand


  • 34. 
    What do you have to fill up when an event transpired is not consistent with routine operation of a health care unit or routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care. These events have the potential to cause injury.
    • A. 

      Injury reports

    • B. 

      Incident reports

    • C. 

      Intervention reports

    • D. 

      Implementation reports


  • 35. 
    Which of the following should not be considered when filling up an incident report?
    • A. 

      Do not admit liability or give unnecessary details

    • B. 

      List date, time and care given to the patient and the name of the Physician notified.

    • C. 

      Personal assessment and judgment of incident

    • D. 

      When charting the incident in the patient's nursing notes, do not mention the incident report.


  • 36. 
    Benefits of a 24-hour patient care records. Select all that apply: 
    • A. 

      Helps eliminate unnecessary record keeping forms

    • B. 

      Enhances efficiency because flow sheets and checklists are often used.

    • C. 

      Accommodates a 24-hour period

    • D. 

      Necessary to maintain a good nursing care plan


  • 37. 
    Uses a score that rates each patient by severity of illness.  
    • A. 

      Acuity charting

    • B. 

      Charting by exception

    • C. 

      Critical pathway

    • D. 

      Traditional Charting


  • 38. 
    One of the benefits of acuity charting is that it provides us with the ability to determine efficient staffing patterns according to the acuity levels of the patients on a particular nursing unit.  
    • A. 

      True

    • B. 

      False


  • 39. 
    When does discharge planning ideally begin?
    • A. 

      During admission

    • B. 

      After admission

    • C. 

      Before admission

    • D. 

      Without admission


  • 40. 
    A systematic approach to care that provides a framework for the coordination of medical and nursing interventions.
    • A. 

      Managed care

    • B. 

      Critical pathway

    • C. 

      Acuity Care

    • D. 

      Intensive care


  • 41. 
    Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply:  
    • A. 

      Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type.

    • B. 

      Clinical pathways that delve with cases occur in high volume and are predictable.

    • C. 

      The clinical pathway replaces other nursing forms such as the nursing care plans

    • D. 

      Charting by exception is usually the method used for clinical pathways

    • E. 

      The exact contents and format of these clinical pathways are the same among different institutions.


  • 42. 
    Which of the following statements about home health care are true? Select all that apply
    • A. 

      It provides a narrower scope of people for a wider majority of services.

    • B. 

      Requires a whole health care team to work closely

    • C. 

      Does not demand meticulous and thorough documentation

    • D. 

      Duplication of documentation is difficult to avoid


  • 43. 
    Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities
    • A. 

      MDS

    • B. 

      DRG

    • C. 

      BCG

    • D. 

      NCLEX


  • 44. 
    An irate patient tells a clerk, "I have paid too much every time I came to this clinic for a physical examination. I think my medical records belong to me. I need them now". What would be the best response.  
    • A. 

      I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

    • B. 

      Your original health care record belongs to the Physician.

    • C. 

      One moment, let me make a copy of it immediately. How many do you want?

    • D. 

      I am so sorry but you really do not have a right to look at your own records.


  • 45. 
    Patients usually do not have immediate access to their full records. There is one exception. What is it?
    • A. 

      County hospitals such as Stroger's Hospital

    • B. 

      University clinics such as PCCTI Nursing lab

    • C. 

      Federal Health Care Agencies such as VA hospitals

    • D. 

      Municipal Health Care Centers such as Oakbrook Health Center


  • 46. 
    What does HIPAA mandate health care personnel with regards to patient's records?  
    • A. 

      Privacy

    • B. 

      Accessibility

    • C. 

      Confidentiality

    • D. 

      Availability


  • 47. 
    What do Electronic Medical Records require from the health care personnel?  
    • A. 

      Log into the system with a secure password

    • B. 

      Log into the system with a common password

    • C. 

      Log into the system with a borrowed password

    • D. 

      Log into the system with a friend's password


  • 48. 
    The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:
    • A. 

      Documentation by the nurse

    • B. 

      Appropriate physician progress notes

    • C. 

      Diagnosis-related groups

    • D. 

      Minimum data sheets


  • 49. 
    While doing clinicals, your nurse preceptor had to leave her station immediately due to a code overheard on the public address system. You observed that the computer  monitor displayed a patients medical history. This patient was not assigned to your care. What should you do next?
    • A. 

      Read the medical history for your own education.

    • B. 

      Turn off the computer as soon as possible

    • C. 

      Print the document to serve as future reference

    • D. 

      Call your clinical instructor and ask what to do


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