Question 1

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 B

Question 2

What makes home health care documentation unique?

Accepted Answer

A)   Some charting is retained at the hospital.
B)   The health care provider's office needs separate charting.
C)   Different health care providers need access.
D)   The health care provider is the pivotal person in the charting. C

Question 3

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

Accepted Answer

documentation

Question 4

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

Accepted Answer

A)   Patient
B)   Health care provider
C)   Institution
D)   State

Question 5

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

Question 6

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

Accepted Answer

A)   Problem list
B)   Nursing orders
C)   Patient problems
D)   Evaluation

Question 7

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

Accepted Answer

A)   Assessment
B)   Planning
C)   Implementation
D)   Evaluation

Question 8

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

Accepted Answer

The answer of A health care audit that evaluates services...

Question 9

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

Question 10

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

Question 11

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

Accepted Answer

The answer of Twenty-four-hour charting is designed to establish __________...

Question 12

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

Accepted Answer

A)   SOAP
B)   Block
C)   CBE
D)   Focus

Question 13

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.

Question 14

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

Accepted Answer

The answer of Documentation using the DARE format (Data,Action,Response,Education)includes elements...

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 health care provider and family members notified
D)   Chronologic order of events of the incident
E)   Confirmation that an incident report was initiated

Question 16

What is the purpose of QA (quality assurance)?

Accepted Answer

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

Question 17

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

Accepted Answer

A)   Include speculation.
B)   Chart consecutively.
C)   Leave blank spaces.
D)   Include retaliatory comments.

Question 18

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.

Question 19

A nurse is receiving a telephone order from a health care provider.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 second step of this method?

Accepted Answer

A)   Read back
B)   Background
C)   Recommendation
D)   Situation
E)   Assessment

Question 20

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

Exam 3: Documentation

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