Question 1

What is the documentation format that uses the acronym SOAPE?

Accepted Answer

A)  Problem-oriented 
B)  Focused 
C)  Traditional 
D)  Crisis 
A)  Problem-oriented 
B)  Focused 
C)  Traditional 
D)  Crisis

Question 2

What form explains the lapse when events are not consistent with facility or national standards of expected care?

Accepted Answer

A)  Subjective data 
B)  Focus chart 
C)  Incident report 
D)  Nursing assessment 
A)  Subjective data 
B)  Focus chart 
C)  Incident report 
D)  Nursing assessment

Question 3

What is the process used to appraise the practice of an individual nurse known as?

Accepted Answer

A)  Quality assurance 
B)  Incident reporting 
C)  OBRA 
D)  Peer review 
A)  Quality assurance 
B)  Incident reporting 
C)  OBRA 
D)  Peer review

Question 4

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

Accepted Answer

A)  nursing order. 
B)  Kardex. 
C)  nursing care plan. 
D)  critical pathway. 
A)  nursing order. 
B)  Kardex. 
C)  nursing care plan. 
D)  critical pathway.

Question 5

What will the nurse implement when an error is made when documenting in a patient's chart?

Accepted Answer

A)  Scratch out the error. 
B)  Apply correction fluid. 
C)  Erase the error completely. 
D)  Draw a single line through the error. 
A)  Scratch out the error. 
B)  Apply correction fluid. 
C)  Erase the error completely. 
D)  Draw a single line through the error.

Question 6

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

Accepted Answer

A)  Provide information only to another nurse. 
B)  Provide information only to an attorney. 
C)  Share information only with the family. 
D)  Have a clinical reason for reading the record. 
A)  Provide information only to another nurse. 
B)  Provide information only to an attorney. 
C)  Share information only with the family. 
D)  Have a clinical reason for reading the record.

Question 7

What regulates standards for long-term care documentation?

Accepted Answer

A)  OBRA 
B)  Title XXII 
C)  Patient problems 
D)  The care plan 
A)  OBRA 
B)  Title XXII 
C)  Patient problems 
D)  The care plan

Question 8

What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply. )

Accepted Answer

A)  Incorrectly recording the time of an event 
B)  Failing to record verbal orders 
C)  Charting events in advance 
D)  Documenting an incorrect date 
E)  Marking out and initialing charting errors 
A)  Incorrectly recording the time of an event 
B)  Failing to record verbal orders 
C)  Charting events in advance 
D)  Documenting an incorrect date 
E)  Marking out and initialing charting errors

Exam 3: Documentation

What is the documentation format that uses the acronym SOAPE?

What form explains the lapse when events are not consistent with facility or national standards of expected care?

What is the process used to appraise the practice of an individual nurse known as?

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

What will the nurse implement when an error is made when documenting in a patient's chart?

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

What regulates standards for long-term care documentation?

What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply. )

The Evolution of Nursing

Legal and Ethical Aspects of Nursing

Communication

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patients Environment

Safety

Admission, transfer, and Discharge

Vital Signs

Physical Assessment

Oxygenation

Elimination and Gastric Intubation

Care of Patients Experiencing Urgent Alterations in Health

Dosage Calculation and Medication Administration

Fluids and Electrolytes

Nutritional Concepts and Related Therapies

Complementary and Alternative Therapies

Pain Management, comfort, rest, and Sleep

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Lifespan Development

Loss, grief, dying, and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, newborn, and Family With Special Needs

Health Promotion for the Infant, child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child With a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient With a Psychiatric Disorder

Care of the Patient With an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Introduction to Anatomy and Physiology

Care of the Surgical Patient

Care of the Patient With an Integumentary Disorder

Care of the Patient With a Musculoskeletal Disorder

Care of the Patient With a Gastrointestinal Disorder

Care of the Patient With a Gallbladder, liver, biliary Tract, or Exocrine Pancreatic Disorder

Care of the Patient With a Blood or Lymphatic Disorder

Care of the Patient With a Cardiovascular or a Peripheral Vascular Disorder

Care of the Patient With a Respiratory Disorder

Care of the Patient With an Endocrine Disorder

Care of the Patient With an Endocrine Disorder

Care of the Patient With a Reproductive Disorder

Care of the Patient With a Visual or Auditory Disorder

Care of the Patient With a Neurologic Disorder

Care of the Patient With an Immune Disorder

Care of the Patient With Hivaids

Care of the Patient With Cancer

Professional Roles and Leadership

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