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ATI DOCUMENTATION EXAM QUESTIONS AND ANSWERS WITH VERIFIED ANSWERS

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? A problem-oriented medical record: is created using the PIE model for documentation entries. contains separate sections for lab and diagnosti...

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? -Immunization data -Record of client health care payments -complete medical info for household members -Facility policies Imm...

A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? Immunization data Reduces medical errors, makes clients medical history more easily available, increases accuracy o...

Health record is an individualized collection of health information and data about a clients health. It also identifies the health services that have been provided, such as hospitalization and procedures is often used as a means of communication among healthcare providers documents a clients sp...

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? The "I" in PIE. The "S" in SOAP. The "R" in DAR. The "E" in PIE. 1 of 20 Term A nurse manager ...

ATI FUNDAMENTALS DOCUMENTATION EXAM QUESTIONS AND ANSWERS WITH VERIFIED ANSWERSA nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? PRN NPO A...