Chapter 3

Question 1

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

Answer 1

c. Interventions were implemented to meet the patient’s needs.

Question 2

Why is documentation especially significant in managed care?
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.

Answer 2

b. Institutions are reimbursed only for patient care that is documented.

Question 3

The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?
a. SOAP
b. Block
c. CBE
d. Focus

Answer 3

c. CBE

Question 4

What form explains the lapse when events are not consistent with facility or national standards of expected care?
a. Subjective data
b. Focus chart
c. Incident report
d. Nursing assessment

Answer 4

c. Incident report

Question 5

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway.

Answer 5

d. critical pathway.

Question 6

What makes home health care documentation unique?
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.

Answer 6

c. Different health care providers need access.

Question 7

What regulates standards for long-term care documentation?
a. OBRA
b. Title XXII
c. Patient problems
d. The care plan

Answer 7

a. OBRA

Question 8

What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical 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.

Answer 8

d. Have a clinical reason for reading the record.

Question 9

Documentation is necessary for the evaluation of patient care. Which of the following phases of the nursing process is necessary for the evaluation of patient care?

a. Assessment
b. Planning
c. Implementation
d. Evaluation

Answer 9

c. Implementation

Question 10

What does the nurse use as a basis for documentation in focus charting? a. Problem list
b. Nursing orders
c. Patient problems
d. Evaluation

Answer 10

c. Patient problems

Question 11

What is the purpose of QA (quality assurance)?
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

Answer 11

b. To evaluate care results against accepted standards

Question 12

What is the process used to appraise the practice of an individual nurse known as?
a. Quality assurance
b. Incident reporting
c. OBRA
d. Peer review

Answer 12

d. Peer review

Question 13

What is the documentation format that uses the acronym SOAPE?
a. Problem-oriented
b. Focused
c. Traditional
d. Crisis

Answer 13

a. Problem-oriented

Question 14

Who is the legal owner of the patient’s medical record?
a. Patient
b. Health care provider
c. Institution
d. State

Answer 14

c. Institution

Question 15

15. 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. Charting in code
    b. Logging off
    c. Charting in privacy
    d. Signing on with a password

Answer 15

b. Logging off

Question 16

What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospitalresources?
a. Quality assurance
b. Resource assessment
c. Quality improvement
d. Diagnosis-related groups

Answer 16

d. Diagnosis-related groups

Question 17

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?
a. Planning
b. Assessment
c. Implementation
d. Patient teaching

Answer 17

b. Assessment

Question 18

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. Health care provider
b. Registered nurse
c. Unlicensed assistive personnel
d. Licensed practical nurse/licensed vocational nurse

Answer 18

b. Registered nurse

Question 19

Which of the following will the nurse implement when an error is made when documenting in a patient’s chart?
a. Scratch out the error.
b. Apply correction fluid.
c. Erase the error completely.
d. Draw a single line through the error.

Answer 19

d. Draw a single line through the error.

Question 20

What should the nurse be sure to do when documenting in a patient’s chart?
a. Include speculation.
b. Chart consecutively.
c. Leave blank spaces.
d. Include retaliatory comments.

Answer 20

b. Chart consecutively.

Question 21

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? a. Read back
b. Background
c. Recommendation
d. Situation
e. Assessment

Answer 21

b. Background

Question 22

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

Answer 22

a. Incorrectly recording the time of an event
b. Failing to record verbal orders
c. Charting events in advance
d. Documenting an incorrect date

Question 23

What are some problems associated with electronic (or computerized) charting? (Select all that apply.)
a. Security
b. Expense of training staff
c. Legibility
d. Easy retrieval
e. New terminology

Answer 23

a. Security
b. Expense of training staff
e. New terminology

Question 24

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

Answer 24

a. Teaching
b. Legal record of care
c. Written communication
d. Research and data collection
e. Permanent record for accountability

Question 25

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

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

Answer 25

a. Care given to the patient
b. Care planned for the patient
c. A patient’s nursing problems
d. A patient’s medical problems
f. The patient’s response to treatment

Question 26

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

Answer 26

documentation

Question 27

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

Answer 27

acuity

Question 28

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

Answer 28

focused

Question 29

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

Answer 29

quality assurance
quality assessment
quality improvement