Charting by exception - Study guides, Class notes & Summaries
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2023/2024 PN HESI Medical-Surgical Test Bank
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HESI Medical-Surgical LPN/PN 
 
Question 1 
The nurse is providing care for a patient who is unhappy with the health care provider’s care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. What should the nurse include in the documentation of this event in the patient’s medical record or on the AMA form? 
1.	Documentation that the patient was informed that he or she cannot come back to the hospital 
2.	Documentation that the patient was i...
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NUR155 / NUR 155 Exam 1 (Latest 2024 / 2025): Foundations of Nursing - Galen
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NUR 155 Foundations of Nursing - Galen College of Nursing 
 
 
Exam 1 
 
 
Question: 
documentation goal 
Answer: 
to describe facts clearly and concisely to improve communication 
 
 
Question: 
correct clear and concise documentation 
Answer: 
"pt voided 150cc clear yellow urine to urinal @ 1230" 
 
 
Question: 
used standardized nursing terminology 
Answer: 
do not use abbreviations. 
example: don't use "QD", use daily. 
 
Question: 
charting by exception 
Answer: 
documentation that re...
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MN Dental Assistant Jurisprudence Exam Questions and Answers 100% Correct
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MN Dental Assistant Jurisprudence Exam Questions and Answers 100% CorrectMN Dental Assistant Jurisprudence Exam Questions and Answers 100% CorrectMN Dental Assistant Jurisprudence Exam Questions and Answers 100% CorrectMN Dental Assistant Jurisprudence Exam Questions and Answers 100% CorrectMN Dental Assistant Jurisprudence Exam Questions and Answers 100% CorrectMN Dental Assistant Jurisprudence Exam Questions and Answers 100% CorrectMN Dental Assistant Jurisprudence Exam Questions and Answers 1...
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Exam 1: PNR104 / PNR 104 (Latest 2024 / 2025 Update) Basic Skills Quality & Safety in Nursing Practice | Guide with Questions and Verified Answers | 100% Correct | Grade A - Fortis
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Exam 1: PNR104 / PNR 104 (Latest 2024 / 2025 Update) Basic Skills Quality & Safety in Nursing Practice | Guide with Questions and Verified Answers | 100% Correct | Grade A - Fortis 
 
 
 
Question: 
Dependent nursing actions 
Answer: 
Actions that need a physician order 
 
 
Question: 
Independent nursing actions 
Answer: 
nursing actions that may be performed based on the nurse's own clinical judgement 
 
 
 
Question: 
What are the forms of Charting 
Answer: 
-source oriented 
-problem oriente...
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Final Exam: NR302 / NR 302 (Latest Update 2024/2025) Health Assessment I |Review with Questions and Verified Answers| 100% Correct -Chamberlain
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Final Exam: NR302 / NR 302 (Latest Update 2024/2025) and Health Assessment I |Review with Questions and Verified Answers| 100% Correct -Chamberlain 
 
 
Q: The nurse is assessing a client's smoking behavior. During the interview, the nurse learns that the client wants to stop smoking but needs help with this behavior change. Which nursing theory would best support the care this client needs? 
 
 A. Health promotion model 
 B. Ecologic model 
 C. Clinical model 
 D. Eudaemonistic model 
 
 
Answ...
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PNR 104 Exam 2 (Answered) Verified Solution
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PNR 104 Exam 2 (Answered) Verified Solution 
Steps of the nursing process in order 
Assessment, nursing dx, planning, implementation, and evaluation 
Assessment and nursing DX 
RN's are responsible for this part of the nursing process 
Data Collection 
LPN's main role in nursing process 
Documentation of the plan 
Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs.)...
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RHIA Practice Exam Questions Domain 1 Questions & Correct Answers | Grade A+
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A method of documenting nurses' progress notes by recording only abnormal or 
unusual findings or deviations from the prescribed plan of care is called: 
a. Problem-oriented progress notes 
b. Charting by exception 
c. Consultative notations 
d. Open charting 
Ans- Charting by exception 
Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the 
discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which 
quality element is missing from Mrs. Smi...
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NSC 232 Final EKU Questions and Answers(A+ Solution guide)
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Documentation Guidelines: Accountability - ️️-sign first name, last name, title to 
each entry 
-do not use dittos, erasers, correcting fluids, etc. 
-identify each page record 
-record is permanent 
Documentation Guidelines: Content - ️️-complete, accurate, concise, factual 
-reflecting nursing process 
-record observations, not interpretation 
-terminology 
-sequencing 
-include safety precautions 
-medical visits, consultations 
-document nursing response to questionable medical order...
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Basic Skills VNSG 1423 Vocational Nursing Exam 3 Blueprint Questions and Correct Answers | Latest Update
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Critical Thinking (definition)- 
 Critical thinking is required to use the nursing process successfully.• 
 Critical thinking means requiring careful judgment.• 
 Critical thinking is directed purposeful mental activity by which ideas 
are evaluated, plans are constructed, and desired outcomes are met 
 Essential for evaluation purposes 
 Clinical reasoning 
Charting by exception 
 use of predetermined standards and norms to record only significant 
assessment care 
Source-oriented 
 char...
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WCU NSG 212 (Exam 1) Dr. BarkerUpdated 2024/2025 Actual Questions and answers with complete solutions
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4 common issues in malpractice caused by inadequate documentation... - -Not charting the 
correct time when events occurred 
-Failing to record verbal orders or failing to have them signed 
-Charting actions in advance to save time 
-Documenting incorrect data 
A professional nurse must perform what portion of the nursing process? - Assessment 
Assessment - Gather data 
Assessment definition - The systematic gathering of information related to the physical, mental, 
spiritual, socioeconomic, and...
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