Documentation (Nursing)
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From Foundations of Nursing by Christensen and Kockrow, pages 138-157
- 1.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- A. Subjective
- A.
- B. Objective
- B.
- C. Assessment
- C.
- D. Plan
- D.
- E. Intervention
- E.
- F. Evaluation
- F.
- G. Revision
- G.
- 17.
- 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.
- 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.
- 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.
- A. D
- A.
- B. A
- B.
- C. R
- C.
- D. E
- D.
- 21.
- 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.
- 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.
- 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.
- A.
Additional treatments done or planned treatments withheld
- B.
Standing orders and physical history
- C.
New Concerns
- D.
Changes in patient condition
- 26.
- 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.
- A. A
- A.
- B. P
- B.
- C. I
- C.
- D. E
- D.
- 28.
- A.
Kardex or Rand
- B.
Nursing Care Plan
- C.
Incident Reports
- D.
24-hour patient care and acuity charting
- E.
Discharge summary
- 29.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
- 30.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.
- 31.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
- 32.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
- 33.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
- 34.
- 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.
- 35.
- 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
- 36.Uses a score that rates each patient by severity of illness.
- A.
Acuity charting
- B.
Charting by exception
- C.
Critical pathway
- D.
Traditional Charting
- 37.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
- 38.When does discharge planning ideally begin?
- A.
During admission
- B.
After admission
- C.
Before admission
- D.
Without admission
- 39.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
- 40.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.
- 41.
- 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
- 42.Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities
- A.
MDS
- B.
DRG
- C.
BCG
- D.
NCLEX
- 43.
- 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.
- 44.
- 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
- 45.What does HIPAA mandate health care personnel with regards to patient's records?
- A.
Privacy
- B.
Accessibility
- C.
Confidentiality
- D.
Availability
- 46.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
- 47.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
- 48.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
- 49.
![]()
- 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
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