Chapter 15- Documentation

1. Each entry or the nurse's recording should begin with

Dear patient

Time

Signature and title

Dear Dr.

2. SOAP stands for: Subjective, Objective, Assessment, Plan

True

False

3. A nurse is caring for six clients on a busy night. She is making rounds to administer drugs. As she administers drugs, when should she document it?

When she is done administering drugs for all patients, so they don't have to wait

As soon as she administers the drug, so she won't forget

Right before administering the drug, so she won't forget

Before she starts any drug administration in order to save time

4. A patient has asked not to be put in the hospital's directory, according to HIPPA's patient rights, this action

Is to be done as the patient wishes

Is to be denied to the patient

Goes by individual cases

5. A nurse is writing a note, she knows that all of the following are important data except:

What she saw

What she heard

What she smelled

What she felt(tactile)

What she thought

6. A nurse is writing a note and remembers the acronym FACTO which of the following does it stand for

Fast, abnormalities, care, topical, oral

Factual, accurate, concise, timely, organized

First, admission, careplan, treatment, options

7. A nurse is documenting a note and she chooses the SOAP note method, she chose this because

All charting focuses on identified problems

It is for communication among nurses only

Subjective data is not necessary in this type of note

8. POC, point of care, documentation promotes all of the following, except

Efficiency

Accuracy

Timeliness

Opportunity for the nurse to document at a later time

9. Clinical pathways are best used for patients with specific, predictable conditions.

True

False

10. Effective communication is important among healthcare providers because

It assures care is safe, timely and responsive to client's need

It eliminates mistakes during client care

It let's the client know what is going on with his/her own care

11. A patient says, "i have sharp pains on my arm." the best way to record this as objectively as possible, would be

To keep the statement in quotations

Record the patient is complaining of pain level 3

Record patient seems to be in pain, his arm hurts

*the question never rated the pain*

Explanation

*the question never rated the pain*

12. When charting, the nurse used all of the following correctly, except:

Shared significant info about family

Gave only essential background info

Evaluated nursing care

Used "good" and "bad" when describing the client's condition

13. The most relevant definition of "source records" is

They are a source of medication administration

They divide the body system and prioritize

They are organized so each discipline has a separate section

14. The nurse is looking for a patient's admission records, where can she find it?

The Kardex

The MAR

The patient's medical record

15. A nurse chooses PIE (problem, intervention, evaluation) notes to document, probably because

She can easily add or eliminate problems, so it is efficient and flexible

It is multidisciplinary

It is difficult to audit

It is for nurses only. It is easily audited.

Explanation

It is for nurses only. It is easily audited.

16. A nurse is writing a note. She is writing in black ink to ensure readable photocopies. Another important concept of her note is:

Be as subjective as possible, because what the client has to say is important

Be as objective as possible, it is interdisciplinary communication

Interpret data and record her interpretations, afterall she is well trained

17. All of the following are purposes of a client record, except:

Communication, it assure continuity of care

Assessment, progress is determined

Reimbursement, for audits

Research, refines the definition of the nursing practice

Access, the client's family can easily understand the client's situation

18. These are all advantages of CBE, charting by exception, except:

Takes less time for immediate documentation

Best where routine care is anticipated

It takes time to develop and maintain

Changes in patient status are readily detected

19. After a teaching session, the nurse documents the session most efficiently by using

DAR note (data, action, response)

PIE note (Problem, Intervention, Evaluation)

SBAR (situation, background, assessment, recommendation)

20. As part of JCAHO standards, the nursing assessment should be documented

Within 8 to 24 hours fo admission

When the healthcareproviders discover the exact cause of the problem

Within the first 3 hours of admission