FOUNDATIONS OF NURSING Chapter 3: Documentation Exam Questions With Correct Answers.
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FOUNDATIONS OF NURSING
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FOUNDATIONS OF NURSING
FOUNDATIONS OF NURSING Chapter 3:
Documentation Exam Questions With
Correct Answers.
The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse
(LPN/LVN) regarding documentation. Which statement by the preceptor is correct? -
answerit is important to use only ...
FOUNDATIONS OF NURSING Chapter 3:
Documentation Exam Questions With
Correct Answers.
The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse
(LPN/LVN) regarding documentation. Which statement by the preceptor is correct? -
answer✔it is important to use only approved medical terms and abbreviations when
documenting in the electronic health record (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 reviewing information regarding the problem-oriented medical record (POMR), the
LPN/LVN correctly identifies which guideline? - answer✔3. the charting format is SOAPE or
SOAPIER
the LPN/LVN is using SOAPE method to chart. When documenting the S portion, which entry
demonstrates correct documentation? (select all that apply). - answer✔2. Patient reports left hip
pain 8/10
5. Patient reports nausea after eating
The 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 mist respect the confidentiality of patient records, which
action by the nurse is appropriate? - answer✔3. Reading charts only for a professional reason
following the 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 correctly completing an incident report with which action?
- answer✔4. Documenting facts regarding the incident
which statement is correct about formats for documentation? (select all that apply). - answer✔3.
Charting by exception documents those conditions, interventions, or outcomes outside the norm.
which statement is a recommended guideline for charting? - answer✔4. The patient's name and
identification number should be on all documents.
which statement is a safe principle of computerized charting? - answer✔4. do not leave patient
information displayed on the monitor.
which accreditation agency specifies guidelines for documentation? - answer✔1. The Joint
Commission (TJC).
What is the primary purpose of Title II of the Health Insurance Portability and Accountability
Act (HIPPA)? - answer✔2. Maintain privacy and confidentiality of patient information
which statement is correct about the abbreviations? (select all that apply). - answer✔1. The
nurse should be aware of any abbreviations on the "do not use list"
4. When in doubt the nurse should use the complete word and not 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 in a facility that uses narrative charting for nurses notes. Identify which
documentation is an example of 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 asking for pain medication for incisional pain 7/10. Hydrocodone 10-325, 2 tablets
administered by mouth while patient was 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 means? - answer✔2.
submitting a written request to the facility to view the record
the charge nurse in a long-term care facility has been asked by the facility administrator to be
sure that the staff documents in a way that will help ensure appropriate reimbursement for
services provided. The charge nurse should instruct the staff to chart using what system as a
guide? - answer✔1. minimum data sets (MDS)
disease classification system that relates the type of inpatients a hospital treats (case mix) to the
costs incurred by the hospital
EHR - answer✔electronic health record.
EHR is shared between one facility to another known as intercommunication
facilitated delivery of patient care and supports the data analysis necessary for coordinating
patient care.
increase efficiency, consistency, accuracy and decreases cost.
EMR - answer✔electronic medical record
EMR is shared between one unit f a facility to another unit in the same facility known as
intracommunication
HIPPA - answer✔Health Insurance Portability and Accountability Act. patient information
privacy and confidentiality.
MDS (minimum data set) - answer✔Resident Assessment protocols in long term care facilities,
and utilization guidelines for each state
POC - answer✔point of care
Charting that is done at the bedside via computerized system
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