Question 1

Expected nursing documentation includes: (Select all that apply.)

Accepted Answer

A)  nursing assessment. 
B)  the care plan. 
C)  critique of the physician's care. 
D)  interventions. 
E)  patient responses to care. 
A)  nursing assessment. 
B)  the care plan. 
C)  critique of the physician's care. 
D)  interventions. 
E)  patient responses to care.

Question 2

If a verbal or phone order is necessary in an emergency, the order:

Accepted Answer

A)  must be taken by an RN or LPN. 
B)  must be repeated verbatim to confirm accuracy. 
C)  documented as a written order. 
D)  does not need further verification by the provider. 
A)  must be taken by an RN or LPN. 
B)  must be repeated verbatim to confirm accuracy. 
C)  documented as a written order. 
D)  does not need further verification by the provider.

Question 3

Accurate documentation by the nurse is necessary since proper documentation:

Accepted Answer

A)  is needed for proper reimbursement. 
B)  must be electronically generated. 
C)  does not involve e-mails or faxes. 
D)  is only legal if written by hand. 
A)  is needed for proper reimbursement. 
B)  must be electronically generated. 
C)  does not involve e-mails or faxes. 
D)  is only legal if written by hand.

Question 4

The use of electronic health records:

Accepted Answer

A)  improves patient health status. 
B)  requires a keyboard to enter data. 
C)  has not been shown to reduce medication errors. 
D)  requires increased storage space. 
A)  improves patient health status. 
B)  requires a keyboard to enter data. 
C)  has not been shown to reduce medication errors. 
D)  requires increased storage space.

Question 5

The nurse is charting using paper nursing notes. The nurse is aware that:

Accepted Answer

A)  attorneys are not allowed access to medical records during litigation. 
B)  when mistakes are made in documentation, the nurse should scribble out the entry. 
C)  only one nurse should document on a sheet so that it can be removed in case of error. 
D)  the medical record is the most reliable source of information in any legal action. 
A)  attorneys are not allowed access to medical records during litigation. 
B)  when mistakes are made in documentation, the nurse should scribble out the entry. 
C)  only one nurse should document on a sheet so that it can be removed in case of error. 
D)  the medical record is the most reliable source of information in any legal action.

Exam 10: Documentation, Electronic Health Records, and Reporting

Expected nursing documentation includes: (Select all that apply.)

If a verbal or phone order is necessary in an emergency, the order:

Accurate documentation by the nurse is necessary since proper documentation:

The use of electronic health records:

The nurse is charting using paper nursing notes. The nurse is aware that:

Nursing, Theory, and Professional Practice

Values, Beliefs, and Caring

Communication

Critical Thinking in Nursing

Introduction to the Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation and Evaluation

Ethical and Legal Considerations

Leadership and Management

Evidence-Based Practice and Nursing Research

Health Literacy and Patient Education

Nursing Informatics

Health and Wellness

Human Development: Conception through Adolescence

Human Development Young Adult to Older Adult

Vital Signs

Health History and Physical Assessment

Ethnicity and Cultural Assessment

Spiritual Health

Public Health, Community Base, and Home Health Care

Human Sexuality

Safety

Asepsis and Infection Control

Hygiene and Personal Care

Activity, Immobility, and Safe Movement

Skin Integrity and Wound Care

Nutrition

Cognitive and Sensory Alterations

Stress and Coping

Sleep

Diagnostic Testing

Medication Administration

Pain Management

Perioperative Nursing Care

Oxygenation and Tissue Perfusion

Fluid, Electrolytes, and Acid-Base Balance

Bowel Elimination

Urinary Elimination

Death and Loss

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