Documentation (Nursing)
(166).jpg "Documentation (Nursing)")
From Foundations of Nursing by Christensen and Kockrow, pages 138-157
- 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.
- 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.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
- 17.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
- 18.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
- 19.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
- 20.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
- 21.Which of the following formats is included under Charting be exception? Select all that apply.
- A.
PIE
- B.
SOAPE
- C.
SOAPIER
- D.
APIE
- 22.
- 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
- 23.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
- 24.
- 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
- 25.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
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