Chapter 7 - Documentation, Nur 101

50 Questions  I  By Arnoldjr2
From Foundations of Nursing by Christensen and Kockrow, pages 138-157

  
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1.  Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply.
A.
B.
C.
D.
E.
2.  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.
3.  Which of the following statements about common forms of inadequate documentation should not be included?
A.
B.
C.
D.
E.
4.  Which of the following practices could lead to malpractice? Select all that apply
A.
B.
C.
D.
E.
5.  Which of the following does not refer to the process of adding written information to a health care record?
A.
B.
C.
D.
6.  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.
B.
C.
D.
7.  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.
B.
C.
D.
8.  Which of the following statements about documenting is not true?
A.
B.
C.
D.
9.  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.
B.
C.
D.
10.  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.
B.
C.
D.
11.  A system used to consolidate patient orders and care needs in a centralized, concise way.  
A.
B.
C.
D.
12.  Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply:  
A.
B.
C.
D.
E.
13.  Which of the following statements about home health care are true? Select all that apply
A.
B.
C.
D.
14.  Which of the following are considered examples of record keeping forms? Select all that apply.
A.
B.
C.
D.
E.
15.  Which of the following is considered a traditional charting?
A.
B.
C.
D.
16.  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.
B.
C.
D.
17.  What do Electronic Medical Records require from the health care personnel?  
A.
B.
C.
D.
18.  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.
B.
C.
D.
19.  When does discharge planning ideally begin?
A.
B.
C.
D.
20.  Match the part of a specific type of documentation with its definition or description on the right
A. Intervention
A.
B. Evaluation
B.
C. Revision
C.
D. Subjective
D.
E. Objective
E.
F. Assessment
F.
G. Plan
G.
21.  Which of the following should not be considered when filling up an incident report?
A.
B.
C.
D.
22.  When is it unnecessary to chart a narrative note? Select all that apply.
A.
B.
C.
D.
23.  Which of the following formats is included under Charting be exception? Select all that apply.
A.
B.
C.
D.
24.  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.
B.
C.
D.
25.  Which of the following are basic purposes  for an accurate and complete written patient records? Select all that apply
A.
B.
C.
D.
E.
26.  Which of the following statements about FOCUS CHARTING is incorrect?
A.
B.
C.
D.
27.  Which of the following statements regarding the DARE format of documentation are correct? Select all that apply
A.
B.
C.
D.
E.
F.
28.  Developed by nurses, it is a modified list of nursing diagnoses used as an index for nursing documentation instead of problem lists.
29.  What kind of notes are taken when charting by exception? Select all that apply.
A.
B.
C.
D.
30.  Based upon the legal guidelines for documentation, which of the following corrective action is incorrect?
A.
B.
C.
D.
31.  Which of the following is a typical section of a traditional chart? Select all that apply
A.
B.
C.
D.
E.
32.  What is the essential difference between PIE and SOAPE formats?
A.
B.
C.
D.
33.  Which of the following statements are true regarding basic rules for documentation. Select all that apply.
A.
B.
C.
D.
E.
34.  The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:
A.
B.
C.
D.
35.  Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities
A.
B.
C.
D.
36.  A systematic approach to care that provides a framework for the coordination of medical and nursing interventions.
A.
B.
C.
D.
37.  Active, inactive potential and resolved problems that serve as the index for charting documentation
A.
B.
C.
D.
38.  In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?
A.
B.
C.
D.
39.  What does HIPAA mandate health care personnel with regards to patient's records?  
A.
B.
C.
D.
40.  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.
B.
41.  Patients usually do not have immediate access to their full records. There is one exception. What is it?
A.
B.
C.
D.
42.  Uses a score that rates each patient by severity of illness.  
A.
B.
C.
D.
43.  Preprinted guidelines used to care for patients with similar health problems.
A.
B.
C.
D.
44.   What is the difference between Traditional and Problem Oriented medical Record charting?
A.
B.
C.
D.
45.  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.
46.  This is the main basis for cost reimbursement rates by government plans
A.
B.
C.
D.
47.  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.
48.  In charting by exception, what happens after the patient's problem is resolved?
A.
B.
C.
D.
49.  In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included? 
A.
B.
C.
D.
50.  Benefits of a 24-hour patient care records. Select all that apply: 
A.
B.
C.
D.
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