Exam 3: Documentation

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A nurse is receiving a telephone order from a physician.The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals.What is the correct order of this method? A) Read back B) Background C) Recommendation D) Situation E) Assessment

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Question 1

Correct Answer:

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D,B,E,C,A
SBAR (Situation,Background,Assessment,and Recommendation)is a method of communication among health care workers and a part of documentation (Kaiser Permanente,2007).SBAR is considered a safety measure in preventing errors from poor communication during "hand-off" or "handover" interactions,the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient.An additional "R" is added.The additional "R" (SBARR)represents "read back" when the nurse reads back the order for clarification.

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

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Question 2

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acuity
Patient acuity,which is reflected in 24-hour charting compilation,can dictate staffing needs.

What is the documentation format that uses the acronym SOAPE?

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(Multiple Choice)

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Question 3

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What does the nurse use as a basis for documentation in focus charting?

(Multiple Choice)

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Question 4

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____.

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Question 5

What should a medical record provide for all health care providers? (Select all that apply.)

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Question 6

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

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Question 7

What should the nurse be sure to do when documenting in a patient's chart?

(Multiple Choice)

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Question 8

What regulates standards for long-term care documentation?

(Multiple Choice)

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Question 9

What makes home health care documentation unique?

(Multiple Choice)

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Question 10

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

(Multiple Choice)

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Question 11

A nurse is using the data,action,response,education (DARE)system of charting,and is completing the data portion.What data are the nurse's focus?

(Multiple Choice)

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Question 12

What is the system that classifies patients by age,diagnosis,and surgical procedure and produces 300 different categories used for predicting the use of hospital resources?

(Multiple Choice)

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Question 13

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

(Multiple Choice)

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Question 14

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

(Multiple Choice)

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Question 15

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

(Multiple Choice)

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Question 16

Who is the legal owner of the patient's medical record?

(Multiple Choice)

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Question 17

The best defense against malpractice claims associated with nursing care is accurate _____________.

(Short Answer)

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Question 18

Why is documentation especially significant in managed care?

(Multiple Choice)

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Question 19

What are the basic purposes of written patient records? (Select all that apply.)

(Multiple Choice)

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Question 20

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Exam 3: Documentation

Twenty-four-hour charting is designed to establish __________ levels to help determine staffing needs.

What is the documentation format that uses the acronym SOAPE?

What does the nurse use as a basis for documentation in focus charting?

A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____________ ________________.

What should a medical record provide for all health care providers? (Select all that apply.)

Documentation using the DARE format (Data,Action,Response,Education)includes elements of the __________ charting system.

What should the nurse be sure to do when documenting in a patient's chart?

What regulates standards for long-term care documentation?

What makes home health care documentation unique?

When using electronic (or computerized)documentation,which process should the nurse use to ensure that no one alters the information the nurse has entered?

A nurse is using the data,action,response,education (DARE)system of charting,and is completing the data portion.What data are the nurse's focus?

What is the system that classifies patients by age,diagnosis,and surgical procedure and produces 300 different categories used for predicting the use of hospital resources?

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

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

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

Who is the legal owner of the patient's medical record?

The best defense against malpractice claims associated with nursing care is accurate _____________.

Why is documentation especially significant in managed care?

What are the basic purposes of written patient records? (Select all that apply.)

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 Patient’s Environment

Safety

Vital Signs

Physical Assessment

Admission, Transfer, and Discharge

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Care of Patients Experiencing Urgent Alterations in Health

Complementary and Alternative Therapies

Pain Management, Comfort, Rest, and Sleep

Nutritional Concepts and Related Therapies

Fluids and Electrolytes

Mathematics and Medication Administration

Care of Patients with Alterations in Health

Life Span 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

Professional Roles and Leadership

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A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____.