Question 1

Why is documentation especially significant in managed care?

Accepted Answer

A) The hospital needs to show that employees care for patients. 
B) Institutions are reimbursed only for patient care that is documented. 
C) Patients might bring lawsuits if care was not given. 
D) Documents may become part of a lawsuit. 
A) The hospital needs to show that employees care for patients. 
B) Institutions are reimbursed only for patient care that is documented. 
C) Patients might bring lawsuits if care was not given. 
D) Documents may become part of a lawsuit.

Question 2

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

Question 3

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 4

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 5

What does documentation of type of care,time of care,and signature of the person prove?

Accepted Answer

A) The person who signed the documentation did all the work noted. 
B) No litigation can be brought against the person who signed. 
C) Interventions were implemented to meet the patient's needs. 
D) The patient's response to the intervention was positive. 
A) The person who signed the documentation did all the work noted. 
B) No litigation can be brought against the person who signed. 
C) Interventions were implemented to meet the patient's needs. 
D) The patient's response to the intervention was positive.

Question 6

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified?

Accepted Answer

A) Health care provider 
B) Registered nurse 
C) Unlicensed assistive personnel 
D) Licensed practical nurse/licensed vocational nurse 
A) Health care provider 
B) Registered nurse 
C) Unlicensed assistive personnel 
D) Licensed practical nurse/licensed vocational nurse

Question 7

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?

Accepted Answer

A) Planning 
B) Assessment 
C) Implementation 
D) Patient teaching 
A) Planning 
B) Assessment 
C) Implementation 
D) Patient teaching

Question 8

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?

Accepted Answer

A) Quality assurance 
B) Resource assessment 
C) Quality improvement 
D) Diagnosis-related groups 
A) Quality assurance 
B) Resource assessment 
C) Quality improvement 
D) Diagnosis-related groups

Exam 3: Documentation

Why is documentation especially significant in managed care?

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

What is the documentation format that uses the acronym SOAPE?

What regulates standards for long-term care documentation?

What does documentation of type of care,time of care,and signature of the person prove?

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the patient problem identified?

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?

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

Professional Roles and Leadership

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