Question 1

Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:

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. D

Question 2

The process used to appraise the practice of an individual nurse is called:

Accepted Answer

A)  quality assurance. 
B)  incident reporting. 
C)  OBRA. 
D)  peer review. 
A)  quality assurance. 
B)  incident reporting. 
C)  OBRA. 
D)  peer review. D

Question 3

When using the data,action,response,education (DARE)system of charting,the data portion focuses on:

Accepted Answer

A)  planning. 
B)  assessment. 
C)  implementation. 
D)  patient teaching. 
A)  planning. 
B)  assessment. 
C)  implementation. 
D)  patient teaching. B

Question 4

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

Accepted Answer

quality assurance/assessment/improvement

Question 5

Home health care documentation is unique because:

Accepted Answer

A)  some charting is retained at the hospital. 
B)  the physician's office needs separate charting. 
C)  different health care providers need access. 
D)  the physician is the pivotal person in the charting. 
A)  some charting is retained at the hospital. 
B)  the physician's office needs separate charting. 
C)  different health care providers need access. 
D)  the physician is the pivotal person in the charting.

Question 6

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

Accepted Answer

A)  Teaching 
B)  Legal record of care 
C)  Written communication 
D)  Research and data collection 
E) Permanent record for accountability
F)Temporary record of hospitalization 
A)  Teaching 
B)  Legal record of care 
C)  Written communication 
D)  Research and data collection 
E) Permanent record for accountability
F)Temporary record of hospitalization

Question 7

Documentation of type of care,time of care,and signature of the person who is documenting proves that:

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 8

When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type,it 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 9

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

Accepted Answer

focused
Focused char

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?

Accepted Answer

A)  Charting in code 
B)  Logging off 
C)  Charting in privacy 
D)  Signing on with a password 
A)  Charting in code 
B)  Logging off 
C)  Charting in privacy 
D)  Signing on with a password

Question 11

The documentation format that uses the acronym SOAPE is:

Accepted Answer

A)  problem-oriented. 
B)  focused. 
C)  traditional. 
D)  crisis. 
A)  problem-oriented. 
B)  focused. 
C)  traditional. 
D)  crisis.

Question 12

The nurse knows that for a hospitalized patient,the legal owner of the patient's medical record is the:

Accepted Answer

A)  patient. 
B)  physician. 
C)  institution. 
D)  state. 
A)  patient. 
B)  physician. 
C)  institution. 
D)  state.

Question 13

When the nurse charts only additional treatments done,changes in patient condition,and new concerns,the system of documentation is:

Accepted Answer

A)  SOAP. 
B)  block. 
C)  CBE. 
D)  focus. 
A)  SOAP. 
B)  block. 
C)  CBE. 
D)  focus.

Question 14

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

Accepted Answer

A)  Care given to the patient 
B)  Care planned for the patient 
C)  A patient's nursing problems 
D)  A patient's medical problems 
E) Details about any incident reports
F)The patient's response to treatment 
A)  Care given to the patient 
B)  Care planned for the patient 
C)  A patient's nursing problems 
D)  A patient's medical problems 
E) Details about any incident reports
F)The patient's response to treatment

Question 15

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

Accepted Answer

A)  Description of injury,including diagrams of injury placement 
B)  Date,time,and location of incident 
C)  Name of physician and family members notified 
D)  Chronological order of events of the incident 
E)  Confirmation that an incident report was initiated 
A)  Description of injury,including diagrams of injury placement 
B)  Date,time,and location of incident 
C)  Name of physician and family members notified 
D)  Chronological order of events of the incident 
E)  Confirmation that an incident report was initiated

Question 16

When documenting in a patient's chart,the nurse should:

Accepted Answer

A)  include speculation. 
B)  chart consecutively. 
C)  leave blank spaces. 
D)  include retaliatory comments. 
A)  include speculation. 
B)  chart consecutively. 
C)  leave blank spaces. 
D)  include retaliatory comments.

Question 17

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

Accepted Answer

A)  Security 
B)  Expense of training staff 
C)  Legibility 
D)  Easy retrieval 
E)  New terminology 
A)  Security 
B)  Expense of training staff 
C)  Legibility 
D)  Easy retrieval 
E)  New terminology

Question 18

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

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.

Question 19

The purpose of QA (quality assurance)is to:

Accepted Answer

A)  screen employment applications. 
B)  evaluate care results against accepted standards. 
C)  conduct in-services for "quality documentation." 
D)  report deviation from standards to the state health department. 
A)  screen employment applications. 
B)  evaluate care results against accepted standards. 
C)  conduct in-services for "quality documentation." 
D)  report deviation from standards to the state health department.

Question 20

When events are not consistent with facility or national standards of expected care,the form that explains the lapse is the:

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.

Exam 7: Documentation

Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:

The process used to appraise the practice of an individual nurse is called:

When using the data,action,response,education (DARE)system of charting,the data portion focuses on:

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

Home health care documentation is unique because:

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

Documentation of type of care,time of care,and signature of the person who is documenting proves that:

When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type,it is known as a:

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

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

The documentation format that uses the acronym SOAPE is:

The nurse knows that for a hospitalized patient,the legal owner of the patient's medical record is the:

When the nurse charts only additional treatments done,changes in patient condition,and new concerns,the system of documentation is:

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

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

When documenting in a patient's chart,the nurse should:

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

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

The purpose of QA (quality assurance)is to:

When events are not consistent with facility or national standards of expected care,the form that explains the lapse is the:

the Evolution of Nursing

Legal and Ethical Aspects of Nursing

Communication

Vital Signs

Physical Assessment

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Life Span Development

Loss, grief , dying, and Death

Admission, Transfer, and Discharge

Medical-Surgical Asepsis and Infection Prevention and Control

Surgical Wound Care

Safety

Body Mechanics and Patient Mobility

Pain Management, Comfort, Rest, and Sleep

Complementary and Alternative Therapies

Hygiene and Care of the Patient’s Environment

Specimen Collection and Diagnostic Examination

Selected Nursing Skills

Basic Nutrition and Nutrition Therapy

Fluids and Electrolytes

Mathematics Review and Medication Administration

Emergency First Aid Nursing

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 Disorder

Care of the Child with a Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Basic 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

Filters

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