Question 1

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

Accepted Answer

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.

Question 2

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

Accepted Answer

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

Question 3

What is the documentation format that uses the acronym SOAPE?

Accepted Answer

A)  Problem-oriented
B)  Focused
C)  Traditional
D)  Crisis A

Question 4

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

Accepted Answer

A)  Problem list
B)  Nursing orders
C)  Nursing diagnoses
D)  Evaluation

Question 5

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 6

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 reportsF)  The patient's response to treatment

Question 7

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 8

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 9

What regulates standards for long-term care documentation?

Accepted Answer

A)  OBRA
B)  Title XXII
C)  Nursing diagnoses
D)  The care plan

Question 10

What makes home health care documentation unique?

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.

Question 11

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

Question 12

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 13

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

Question 14

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

Accepted Answer

A)  Scratch out the error
B)  Apply correction fluid
C)  Erase the error completely
D)  Draw a single line through the error

Question 15

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

Accepted Answer

A)  Quality assurance
B)  Incident reporting
C)  OBRA
D)  Peer review

Question 16

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

Question 17

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

Accepted Answer

A)  Patient
B)  Physician
C)  Institution
D)  State

Question 18

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

Accepted Answer

The answer of The best defense against malpractice claims associated...

Question 19

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 20

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 accountabilityF)  Temporary record of hospitalization

Exam 3: Documentation