Nursing documentation quiz

1. _________ is a traditional charting?

Narrative

Problem-Oriented Medical Record

SOAPE

DARE

Traditional charting methods often involve a narrative format, where healthcare professionals document patient information in a free-text paragraph style. In narrative charting, events and observations are recorded in a chronological order, providing a comprehensive overview of the patient's condition and care.

Explanation

Traditional charting methods often involve a narrative format, where healthcare professionals document patient information in a free-text paragraph style. In narrative charting, events and observations are recorded in a chronological order, providing a comprehensive overview of the patient's condition and care.

2. When does discharge planning ideally begin?

During admission

After admission

Before admission

Without admission

Discharge planning is a process that aims to ensure a smooth transition from hospital to home or another facility. Ideally, discharge planning should begin during admission. This allows healthcare providers to understand the patient’s needs and plan for appropriate care and resources after discharge.

Explanation

Discharge planning is a process that aims to ensure a smooth transition from hospital to home or another facility. Ideally, discharge planning should begin during admission. This allows healthcare providers to understand the patient’s needs and plan for appropriate care and resources after discharge.

3. The right difference between PIE and SOAPE formats is

SOAPE is from a medical model, whereas PIE is from the nursing process.

PIE is part of a medical model, and SOAPE is not.

Both are same

PIE is a part of SOAPE.

In summary, the key difference between the PIE (Problem, Intervention, Evaluation) and SOAPE (Subjective, Objective, Assessment, Plan, and sometimes Education) documentation formats lies in their conceptual origins. SOAPE is derived from a medical model, often used in medical and healthcare settings, while PIE is rooted in the nursing process, emphasizing the nurse's role in identifying problems, planning and implementing interventions, and evaluating outcomes. This distinction reflects the underlying approaches to patient care and documentation in medical and nursing contexts, respectively.

Explanation

In summary, the key difference between the PIE (Problem, Intervention, Evaluation) and SOAPE (Subjective, Objective, Assessment, Plan, and sometimes Education) documentation formats lies in their conceptual origins. SOAPE is derived from a medical model, often used in medical and healthcare settings, while PIE is rooted in the nursing process, emphasizing the nurse's role in identifying problems, planning and implementing interventions, and evaluating outcomes. This distinction reflects the underlying approaches to patient care and documentation in medical and nursing contexts, respectively.

4. APIE is a variation of the PIE documentation. Match the element of the documentation on the left with an example on the right.

A

P

I

E

Assessment: The initial step involves gathering and analyzing information about the patient's condition. This includes both subjective data (information provided by the patient) and objective data (measurable and observable information).

Planning: Based on the assessment, a plan of care is developed. This plan outlines the goals, interventions, and expected outcomes for addressing the identified issues or problems.

Implementation: This phase involves carrying out the planned interventions and providing the necessary care. Implementation includes executing the nursing interventions outlined in the plan of care.

Evaluation: After implementing the interventions, the effectiveness of the care plan is assessed. Evaluation involves analyzing the patient's response to the interventions and determining whether the goals have been met or if adjustments to the plan are necessary.

Explanation

Assessment: The initial step involves gathering and analyzing information about the patient's condition. This includes both subjective data (information provided by the patient) and objective data (measurable and observable information).

Planning: Based on the assessment, a plan of care is developed. This plan outlines the goals, interventions, and expected outcomes for addressing the identified issues or problems.

Implementation: This phase involves carrying out the planned interventions and providing the necessary care. Implementation includes executing the nursing interventions outlined in the plan of care.

Evaluation: After implementing the interventions, the effectiveness of the care plan is assessed. Evaluation involves analyzing the patient's response to the interventions and determining whether the goals have been met or if adjustments to the plan are necessary.

Submit

5. ______ is not in the process of adding valuable written information to a healthcare record.

Recording

Charting

Data entry

Documenting

“Data entry” generally refers to the act of inputting data into a system or database, but it doesn’t necessarily imply that the data being entered is valuable or meaningful in the context of a healthcare record. Therefore, the correct answer is C.

Explanation

“Data entry” generally refers to the act of inputting data into a system or database, but it doesn’t necessarily imply that the data being entered is valuable or meaningful in the context of a healthcare record. Therefore, the correct answer is C.

6. What kind of documentation is the following? 0800-1300 0 45, pain scale 0/10, hand and leg, strong to the right, weak to the left. Skin pink, warm and dry, turgor good, incision to Rt. Anterior chest wall erythema or edema ...................Jane Night, LPN.

Kardex

Narrative

Nurse's Notes

Shift report

The answer is, "Narrative" because the documentation provided appears to be a detailed account of a patient’s condition, including vital signs, pain scale, physical assessment, and the nurse’s observations. This type of detailed, chronological account is typically found in Nurse’s Notes. Nurse’s Notes are used to document a patient’s condition and the care that has been given, including the administration of drugs, the performance of procedures, and the patient’s response to treatment.

Explanation

The answer is, "Narrative" because the documentation provided appears to be a detailed account of a patient’s condition, including vital signs, pain scale, physical assessment, and the nurse’s observations. This type of detailed, chronological account is typically found in Nurse’s Notes. Nurse’s Notes are used to document a patient’s condition and the care that has been given, including the administration of drugs, the performance of procedures, and the patient’s response to treatment.

7. Match the part of a specific type of documentation with its definition or description on the right

Intervention

Evaluation

Revision

Subjective

Objective

Assessment

Plan

Intervention refers to the hands-on actions or treatments that the healthcare provider implements as part of the patient's care plan.

Evaluation involves assessing how well the implemented interventions or care plan are working and whether they are achieving the desired outcomes.

Revision is when the evaluation reveals the need for adjustments, and revision involves making changes to the initial care plan to address the patient's needs better.

Subjective information is based on the patient's feelings, perceptions, and experiences, and it is crucial for understanding their condition.

Objective data involves observable and measurable information, such as vital signs, laboratory results, and physical examination findings.

Assessment involves a comprehensive analysis of the patient's condition, including gathering subjective and objective data to identify issues or potential health problems.

The plan outlines the proposed course of action, including interventions and strategies to address the patient's needs based on the assessment and identified problems.

Explanation

Intervention refers to the hands-on actions or treatments that the healthcare provider implements as part of the patient's care plan.

Evaluation involves assessing how well the implemented interventions or care plan are working and whether they are achieving the desired outcomes.

Revision is when the evaluation reveals the need for adjustments, and revision involves making changes to the initial care plan to address the patient's needs better.

Subjective information is based on the patient's feelings, perceptions, and experiences, and it is crucial for understanding their condition.

Objective data involves observable and measurable information, such as vital signs, laboratory results, and physical examination findings.

Assessment involves a comprehensive analysis of the patient's condition, including gathering subjective and objective data to identify issues or potential health problems.

The plan outlines the proposed course of action, including interventions and strategies to address the patient's needs based on the assessment and identified problems.

Submit

8. This is the main basis for cost reimbursement rates by government plans.

Patient expense documentation

Critical pathway

Minimum datasheet

Diagnosis related groups

Diagnoses Related Groups (DRGs) serve as the main basis for cost reimbursement rates by government plans. DRGs are a system used in healthcare to categorize hospital cases into groups based on similar clinical conditions and procedures. This classification system is crucial for determining the appropriate reimbursement rates for healthcare services provided.

Explanation

Diagnoses Related Groups (DRGs) serve as the main basis for cost reimbursement rates by government plans. DRGs are a system used in healthcare to categorize hospital cases into groups based on similar clinical conditions and procedures. This classification system is crucial for determining the appropriate reimbursement rates for healthcare services provided.

9. In the DARE format of documentation, match the elements of the documentation with the corresponding situation on the right.

D

A

R

E

D (Data): "Twisting in bed, grimacing with movement" represents the data or information gathered during the assessment phase. It describes the observable and measurable signs of discomfort or pain.

A (Action): "Administered morphine sulfate" is the action taken based on the assessment. It represents the intervention or care provided to address the identified issue.

R (Response): "Verbalized relief within 15 minutes lying quietly" signifies the patient's response to the intervention. It indicates the effectiveness or outcome of the action taken.

E (Education): "Instructed patient to move slowly when getting out of bed" represents the educational component of care. It involves providing guidance to the patient to prevent further discomfort or injury.

Explanation

D (Data): "Twisting in bed, grimacing with movement" represents the data or information gathered during the assessment phase. It describes the observable and measurable signs of discomfort or pain.

A (Action): "Administered morphine sulfate" is the action taken based on the assessment. It represents the intervention or care provided to address the identified issue.

R (Response): "Verbalized relief within 15 minutes lying quietly" signifies the patient's response to the intervention. It indicates the effectiveness or outcome of the action taken.

E (Education): "Instructed patient to move slowly when getting out of bed" represents the educational component of care. It involves providing guidance to the patient to prevent further discomfort or injury.

Submit

10. Match the method of recording on the left with an example of the documentation type on the right.

Traditional

Problem-Oriented Medical Record

Focus Charting Format

Charting by exception

Record-keeping forms

Traditional

Example: Record-keeping forms

Explanation: Traditional record-keeping often involves using structured forms to document various aspects of patient care.

Narrative

Example: SOAPE, SOAPIER

Explanation: Narrative charting involves the use of paragraphs or free-text entries to provide a comprehensive description of the patient's condition and care.

Problem-Oriented Medical Record

Example: DAR, DARE

Explanation: Problem-oriented medical records use a systematic approach where each problem is addressed individually, and documentation includes Data, Action, and Response (DAR/DARE) related to specific problems.

Focus Charting Format

Example: APIE, PIE

Explanation: Focus charting is centered around a specific focus or concern, and documentation follows the APIE (Assessment, Planning, Implementation, Evaluation) or PIE (Problem, Intervention, Evaluation) format.

Charting by Exception

Example: Kardex, Nursing Care Plans

Explanation: Charting by exception involves documenting only significant deviations from the expected norm. Kardex and Nursing Care Plans may be used to document care plans and significant information.

Explanation

Traditional

Example: Record-keeping forms

Explanation: Traditional record-keeping often involves using structured forms to document various aspects of patient care.

Narrative

Example: SOAPE, SOAPIER

Explanation: Narrative charting involves the use of paragraphs or free-text entries to provide a comprehensive description of the patient's condition and care.

Problem-Oriented Medical Record

Example: DAR, DARE

Explanation: Problem-oriented medical records use a systematic approach where each problem is addressed individually, and documentation includes Data, Action, and Response (DAR/DARE) related to specific problems.

Focus Charting Format

Example: APIE, PIE

Explanation: Focus charting is centered around a specific focus or concern, and documentation follows the APIE (Assessment, Planning, Implementation, Evaluation) or PIE (Problem, Intervention, Evaluation) format.

Charting by Exception

Example: Kardex, Nursing Care Plans

Explanation: Charting by exception involves documenting only significant deviations from the expected norm. Kardex and Nursing Care Plans may be used to document care plans and significant information.

Submit

Nursing Documentation Quiz