Question 1

What should the nurse be sure to do when documenting in a patient's chart?

Accepted Answer

A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse's notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line.

Question 2

What regulates standards for long-term care documentation?

Accepted Answer

OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation.

Question 3

What is the purpose of QA (quality assurance)?

Accepted Answer

QA is an in-house department that evaluates care services and results against accepted standards.

Question 4

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?

Accepted Answer

DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E).

Question 5

What makes home health care documentation unique?

Accepted Answer

Home health care documentation has unique problems because of the need for different health care workers to access the medical record.

Question 6

The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?

Accepted Answer

Charting additional treatments done, changes in a patient's condition, and new concerns during the shift is charting by exception (CBE).

Question 7

What is the documentation format that uses the acronym SOAPE?

Accepted Answer

The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems/nursing diagnoses.

Question 8

Why is documentation especially significant in managed care?

Accepted Answer

Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.

Question 9

Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part?

Accepted Answer

Documentation is part of the implementation phase of the nursing process.

Question 10

What is the system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources?

Accepted Answer

Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.

Question 11

What will the nurse implement when an error is made when documenting in a patient's chart?

Accepted Answer

A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient's chart. Instead, the nurse should draw a single line through the error, write the word "error" above it, and sign her name or initials.

Question 12

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:

Accepted Answer

Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.

Question 13

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

Accepted Answer

Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include doctor's visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive.

Question 14

What does the nurse use as a basis for documentation in focus charting?

Accepted Answer

In focus charting, instead of using the problem list, modified nursing diagnoses are used as an index for nursing documentation.

Question 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?

Accepted Answer

Logging off closes the computer file that was opened with the nurse's password. Any other data entry will require that person to sign on with their password.

Question 16

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 nursing diagnoses identified?

Accepted Answer

The registered nurse (RN) has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified.

Question 17

What form explains the lapse when events are not consistent with facility or national standards of expected care?

Accepted Answer

An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified.

Question 18

What is the process used to appraise the practice of an individual nurse known as?

Accepted Answer

Peer review is an in-house department study that may appraise the nursing practice of individual nurses.

Question 19

Who is the legal owner of the patient's medical record?

Accepted Answer

Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the physician in the case of private office visits.

Question 20

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

Accepted Answer

The nurse should not read the patient's medical record unless there is a clinical reason for doing so.

Quiz 3: Documentation