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FOUNDATIONS OF NURSING Chapter 3 Documentation Exam Latest Update
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FOUNDATIONS OF NURSING Chapter 3 Documentation Exam Latest Update...
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FOUNDATIONS OF NURSING Chapter 3Documentation Exam Latest Update
The nursing preceptor is going to discuss documentation with the new LPN/LVN. Which
of the following statements do you believe is correct by the preceptor? ANSWER It is
essential to use only approved medical terms and abbreviations when documenting in
the EHR.
The patient asks the LPN/LVN if he can take his chart with him on discharge from the
hospital. Which response by the nurse is most accurate? - Answer "the chart is the
property of the hospital, but if you need copies of your records, we can arrange that for
you."
When comparing data regarding the problem-oriented medical record (POMR), the
LPN/LVN identifies which principle correctly? - Answer 3. the charting format is SOAPE
or SOAPIER
The LPN/LVN is applying the SOAPE method to chart. For the S portion of the
documentation which entry is correct documentation? (select all that apply). - Answer 2.
Patient states left hip pain 8/10
5. Patient states nausea after eating
A student nurse is correct when identifying which concept regarding documentation as
being correct? Answer 1. chart as soon and as often as necessary
understanding that health care personnel must respect the confidentiality of patient
records, which action by the nurse is appropriate? Answer 3. Reading charts only for a
professional reason
Following orientation to the facility's computer system which statement by the new
nurse is most accurate? -Answer 1. "I can save on charting time once I am comfortable
,using the system."
The nurse demonstrates knowledge of appropriately completing an incident report with
which action? -Answer 4. Documenting facts regarding the incident
Which of the following statements is true regarding documentation formats? (Select all
that apply). Answer 3. Charting by exception documents those conditions, interventions,
or outcomes outside the norm.
5. EHR systems permit the sharing of the patient date for the purposes of collaborative
care
Which statement is one of the guidelines for charting? Answer 4. The patient's name and
identification number should be on all documents.
Which of the following is a safe principle of computerized charting? Answer 4 Do not
leave patient information displayed on the monitor.
Which accrediting agency is responsible for specific guidelines related to
documentation? Answer 1 The Joint Commission (TJC).
What is the primary purpose of Title II of HIPPA? Answer 2 To maintain the patient
information private and confidential.
Which of the following is correct concerning the abbreviations? (Choose all that apply).
1. The nurse should know those abbreviations that are on the "do not use list"
4. If unsure in any situation, the nurse spelling out the word will avoid using the
abbreviation.
The nurse documents in the patient record, "0830 patient appears to be in severe pain
and refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and
analgesic administered as ordered with adequate relief. J. Doe RN." Which statement
about the documentation is most accurate? -Answer 4. The documentation is
unacceptable because it is vague, non-descriptive data without supportive data.
, The nurse works for an agency that uses narrative charting for nurse's notes. Choose
which documentation is narrative charting. (select all that apply). - Answer 1. patient
alert and oriented x3, PERRLA, hand grips strong and equal
3. patient ambulated 60 ft in the hall, unassisted with steady gait. Currently resting in
chair with no complaints.
5. Patient requesting pain medication for incisional pain 7/10. Hydrocodone 10-325, 2
tabs po given while patient eating lunch. Patient resting in bed with side rails up x 2 and
call light in reach
in most states patients can gain access to their medical records by which following
means? - Answer 2. submitting a written request to the facility to view the record
The facility administrator has asked the charge nurse in a long-term care facility to be
sure that the staff documents in a way that will help ensure appropriate reimbursement
for services provided. Where should the charge nurse instruct the staff to chart using
what system as a guide? Response 1 minimum data sets (MDS)
An older adult client is admitted to an acute care facility with the diagnosis of
pneumonia. Medicare will reimburse the facility for 4 days of care. For what following
Prospective Payment System is responsible for this reimbursement? - Answer 4.
Diagnosisrelated groups (DRGs)
CBE - Answer Charting by Exception.
focuses on documenting deviations from the norm
DRGs - Answer Diagnosis Related Groups,
classification system that relates the type of inpatients a hospital treats to the costs
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