Question 1

A nurse is documenting the last entry for the day.It is 3:15 PM and the agency uses military time.Which time should the nurse enter?
A) 315
B) 0315
C) 1315
D) 1515

Accepted Answer

3:15 is 1515 in military time (1200 + 315 = 1515).The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400.For example,10:22 AM is 1022 military time; 1:00 PM is 1300 military time.

Question 2

Which documentation by the nurse is most appropriate?
A) "The patient states would except moving to a semi-private room."
B) "Developed aspiration pneumonia due to dysphasia."
C) "Bruise noted on right side over fractured abdimin."
D) "Right jugular vein distended."

Accepted Answer

Right jugular vein distended is the only entry without spelling errors.Correct spelling demonstrates competency and attention to detail.Misspelled words lead to confusion.For example,often words sound the same but have different meanings such as accept and except or dysphagia and dysphasia.Misspellings and incorrect use of terms alters the intended meaning.Not only is abdomen misspelled,but an abdomen cannot be fractured.

Question 3

Which information indicates the nurse has a correct understanding of the purpose of a patient's medical record?
A) To invoice the nurse for reimbursement
B) To protect the patient in case of a malpractice suit
C) To ensure everyone is working toward a common goal of providing safe care
D) To contribute to a worldwide databank for trends in health care

Accepted Answer

The medical record helps to ensure that all health team members are working toward a common goal of providing safe and effective care.Documentation can be used for reimbursement but it is not to invoice the nurse,but to invoice patients and/or insurance companies.It protects the clinician in cases of a malpractice suit,not the patient.It does not contribute to a worldwide databank for trends in health care,but it can be used for medical or nursing research.

Question 4

A registered nurse is caring for an older adult patient with lung cancer.The daughter,who is also a nurse,asks to see the chart.What is the nurse's best response?
A) "Come with me and we will look at it together."
B) "I'm sorry; this information is confidential."
C) "Let me ask my supervisor if it is okay."
D) "You should know better than to ask me that."

Accepted Answer

Do not disclose information about patients' status to other patients,family members (unless granted by the patient),or health care staff not involved in their care.Looking at it together is not acceptable because confidentiality would be broken.Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality.Saying,"You should know better than to ask me that" is inappropriate and condescending.

Question 5

The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing,which are determined by an acuity system.The nurse manager notices that the acuity level is high.What should the nurse manager do?
A) More staff may be needed.
B) Talk to the patients.
C) Less staff may be needed.
D) Talk to the families.

Accepted Answer

A high acuity means more staff may be needed.An acuity recording system determines the hours of care for a nursing unit and the number of staff required to care for a given group of patients.A low acuity would mean less staff is needed.Talking to the patients or family is not related to the acuity level.

Question 6

Which documentation by the nurse best describes patient data?
A) "Moderate amount of clear yellow urine voided."
B) "Voided 220 mL clear yellow urine."
C) "A small amount of urine voided into absorbent pad."
D) "Patient incontinent of urine."

Accepted Answer

The use of precise measurements makes documentation more accurate.For example,documenting "Voided 450 mL clear urine" is more accurate than "Voided an adequate amount." Small and moderate are not as accurate as precise measurement.Patient incontinent of urine does not tell how much and although accurate is not as accurate as a precise measurement.

Question 7

Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?
A) "Sm. amt. of emesis."
B) "150 mL of cloudy dark yellow urine."
C) "Had a good day."
D) "Looks bad."

Accepted Answer

150 mL of cloudy dark yellow urine is the best.The use of precise measurements makes documentation more accurate.To avoid misunderstandings and promote patient safety,write out any abbreviations that are possibly confusing.Avoid using generalized,empty phrases,such as "had a good day." Be objective and factual; do not use "looks bad" because it is vague and too general.

Question 8

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation.The nurse charts the following: Discuss alternatives for pain control.Which component of SOAP did the nurse chart?
A) S
B) O
C) A
D) P

Accepted Answer

Discuss alternatives for pain control is a Plan.SOAP is an acronym for the following:
S: Subjective data (verbalizations of the patient)
O: Objective data (data that are measured and observed)
A: Assessment (diagnosis based on the subjective and objective data)
P: Plan (what the caregiver plans to do)

Question 9

A nurse works at a health care organization that is accredited by The Joint Commission.What is the best method for this health care organization to demonstrate that it is providing quality patient care?
A) Cost of care per patient day
B) Number of registered nurses
C) Absence of sentinel events
D) Documentation audits

Accepted Answer

Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care.Typically,such monitoring and evaluations occur through the auditing of information health care providers document in patient records.It does not include cost of care per patient day,number of RNs,nor absence of sentinel events.

Question 10

A nursing student is working on a clinical assignment.Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?
A) Patient room number
B) Patient date of birth
C) Patient medical record number
D) Patient nursing diagnosis

Accepted Answer

The nursing diagnosis is acceptable information to give to a nursing instructor.To further maintain confidentiality and protect patient privacy,make sure written materials used in student clinical practice do not have patient identifiers,such as room number,date of birth,medical record number,or other identifiable demographic information.

Question 11

A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR.What will the nurse be charting?
A) Data, assessment, reaction
B) Data, assessment, recommendation
C) Data, actions, response
D) Data, actions, recovery

Accepted Answer

Each entry includes data,actions,and patient response (DAR)for the particular patient situation.Focus charting (DAR)is a unique narrative format in that it places less emphasis on patient problems and instead focuses on patient concerns such as a sign or symptom,a condition,a behavior,or a significant event.There are no reaction,recommendation,recovery,or assessment in DAR.

Question 12

A registered nurse is documenting patient assessments.Which documentation written by the nurse is most clear?
A) "Seems comfortable at this time."
B) "Is asleep, appears not to be experiencing pain."
C) "Apparently is not in pain because patient didn't rate it high on the scale."
D) "States pain is a 2 on a 0 to 10 scale."

Accepted Answer

States pain is a 2 is factual.To be factual,avoid words such as appears,seems,or apparently because they are vague and lead to conclusions that cannot be supported by objective information.

Question 13

A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE.What will the nurse be charting?
A) Problem, intervention, evaluation
B) Patient, interview, evaluation
C) Population, intervention, encourage
D) Plan, interview, enhance

Accepted Answer

PIE is an acronym for problem,interventions,evaluation as follows:
P: Problem or nursing diagnosis applicable to patient
I: Interventions or actions taken
E: Evaluation of the outcomes of nursing interventions
The PIE format simplifies documentation by unifying the care plan and progress notes into a complete record.PIE does not include patient,population,or plan.It also does not have encourage or enhance.

Question 14

Which information by a nurse indicates more teaching is needed about The Joint Commission's requirements for writing plans of care?
A) A care plan must be developed for patients in a clinic.
B) A care plan must be developed for patients in an acute care hospital.
C) A care plan must be developed for patients in a rehabilitation agency.
D) A care plan must be developed for patients in an extended care facility.

Accepted Answer

The question indicates the nurse needs more teaching and The Joint Commission does not require a care plan for clinic patients.The Joint Commission standards require that a care plan,also called a "plan of care," be developed for all patients on admission to acute,subacute,rehabilitation,or extended care agencies.

Question 15

A nurse began working at a local hospital and learned that the hospital had just instituted a "hand-off" protocol.What will the nurse be doing?
A) Performing transfer reports
B) Completing IV fluid flow sheets
C) Using standardized care plans
D) Reviewing laboratory reports

Accepted Answer

Examples of hand-off reports include change-of-shift reports and transfer reports.A hand-off report occurs any time one health care provider transfers care of a patient to another health care provider.The purpose of hand-off reports is to provide better continuity and individualized care for patients.Flow sheets are part of the permanent health record and provide a quick and easy reference for assessing changes in a patient's status.Standardized care plans,based on institution standards of nursing practice,are preprinted established guidelines of care for patients with similar health problems.The laboratory submits a written report providing the results of diagnostic tests.

Question 16

A registered nurse recently changed jobs and is now working in home health.What must the nurse chart to obtain reimbursement from Medicare,Medicaid,and private insurance companies?
A) Patient's response to care
B) Whether patient had a good or bad day
C) Whether family liked nurse or not
D) Patient's number of marriages

Accepted Answer

When you provide home care,your documentation must specifically address the category of care and your patient's response to care.Good or bad day is not factual or objective information.Whether family liked nurse or not and the number of marriages does not affect reimbursement.

Question 17

A patient states that he or she is experiencing pain in the lower back.What is the best way for the nurse to document this subjective information?
A) "Seems back is hurting."
B) "States 'My lower back hurts.'"
C) "Grimaces when moving; I believe patient has lower back pain."
D) "Appears to be uncomfortable with lower back pain."

Accepted Answer

The only subjective data included in a record are what the patient says.Write subjective information with quotation marks,using the patient's own words.For example,a patient's statement of "My lower back hurts" is subjective and acceptable documentation.Seems and appears should be avoided.A factual record contains descriptive,objective information about what you see,hear,feel,and smell,not the nurse's opinions.

Question 18

A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale.Which component of SBAR did the nurse communicate?
A) S
B) B
C) A
D) R

Accepted Answer

For assessment (A)data include significant findings in your head-to-toe physical assessment,recent vital signs,current treatment measures,restrictions,recent laboratory results and diagnostics,and pain status.Some institutions use SBAR,an acronym that stands for situation,background,assessment,and recommendation.SBAR standardizes telephone communication of significant events or changes in a patient's condition.Therefore it is a communication strategy designed to improve patient safety.When describing the situation (S),you include the admitting and secondary diagnoses and the problem your patient is having as the current issue.Background (B)information includes pertinent medical history,previous laboratory tests and treatments,psychosocial issues,allergies,and current code status.Provide your recommendation (R),in which you suggest a plan of care and request orders and other needs to be addressed.

Question 19

A nurse is working in an agency with standards that require a nurse's documentation to be within the context of the nursing process.The nurse is working for which agency?
A) Centers for Disease Control and Prevention accredited hospital
B) World Health Organization hospital
C) The Joint Commission accredited hospital
D) Agency for Healthcare Research and Quality hospital

Accepted Answer

The Joint Commission standard for record of care,treatment,and services requires that your documentation be within the context of the nursing process,including evidence of patient and family teaching and discharge planning.Other standards include those directed by state and federal regulatory agencies such as HIPAA,as enforced through the Department of Justice,and the Centers for Medicare and Medicaid Services.

Question 20

A nurse is frustrated about the lack of staffing for the shift.When one of the patients fell and broke a hip,the nurse documented the incident in the patient's chart.Which entry is the best way that the nurse should document what happened?
A) "Patient stated that fell while going to the bathroom. Physician notified."
B) "Nobody available to answer call bell; patient got up on own and fell."
C) "Patient fell because of unsafe staffing levels on unit."
D) "Patient waited as long as possible but nobody there to help and fell."

Accepted Answer

Charting should be factual.Patient stated that fell is the most factual.Do not write retaliatory or critical comments about patient or care by other health care professionals.Statements that are retaliatory or critical can be used as evidence for nonprofessional behavior or poor quality of care.Nobody available to answer call bell,fell because of unsafe staffing levels,or nobody to help are all retaliatory or critical comments and should not be used.

Quiz 10: Informatics and Documentation

A nurse is documenting the last entry for the day.It is 3:15 PM and the agency uses military time.Which time should the nurse enter?

Which documentation by the nurse is most appropriate?

Which information indicates the nurse has a correct understanding of the purpose of a patient's medical record?

A registered nurse is caring for an older adult patient with lung cancer.The daughter,who is also a nurse,asks to see the chart.What is the nurse's best response?

The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing,which are determined by an acuity system.The nurse manager notices that the acuity level is high.What should the nurse manager do?

Which documentation by the nurse best describes patient data?

Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation.The nurse charts the following: Discuss alternatives for pain control.Which component of SOAP did the nurse chart?

A nurse works at a health care organization that is accredited by The Joint Commission.What is the best method for this health care organization to demonstrate that it is providing quality patient care?

A nursing student is working on a clinical assignment.Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor?

A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR.What will the nurse be charting?

A registered nurse is documenting patient assessments.Which documentation written by the nurse is most clear?

A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE.What will the nurse be charting?

Which information by a nurse indicates more teaching is needed about The Joint Commission's requirements for writing plans of care?

A nurse began working at a local hospital and learned that the hospital had just instituted a "hand-off" protocol.What will the nurse be doing?

A registered nurse recently changed jobs and is now working in home health.What must the nurse chart to obtain reimbursement from Medicare,Medicaid,and private insurance companies?

A patient states that he or she is experiencing pain in the lower back.What is the best way for the nurse to document this subjective information?

A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale.Which component of SBAR did the nurse communicate?

A nurse is working in an agency with standards that require a nurse's documentation to be within the context of the nursing process.The nurse is working for which agency?

A nurse is frustrated about the lack of staffing for the shift.When one of the patients fell and broke a hip,the nurse documented the incident in the patient's chart.Which entry is the best way that the nurse should document what happened?