Documentation (Nursing)

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Documentation (Nursing)

From Foundations of Nursing by Christensen and Kockrow, pages 138-157


Questions and Answers
  • 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