NCLEX Practice Questions - Documentation - (Almost) !!!No Rationales!!!

Which of the following does not refer to the process of adding written information to a health care record?

Data entry

Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply. A. Database B. Problem list C. Care plan D. Physical examination and diagnostic tests E. Referral form

A, B, C, D

Benefits of a 24-hour patient care records. Select all that apply: A. Helps eliminate unnecessary record keeping forms B. Enhances efficiency because flow sheets and checklists are often used. C. Accommodates a 24-hour period D. Necessary to maintain a good nursing care plan

A, B, C

Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply: A. Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type. B. Clinical pathways that delve with cases occur in high volume and are predictable. C. The clinical pathway replaces other nursing forms such as the nursing care plans D. Charting by exception is usually the method used for clinical pathways E. The exact contents and format of these clinical pathways are the same among different institutions.

A, B, C, D

Which of the following are considered examples of record keeping forms? Select all that apply. A.Kardex or Rand B. Nursing Care Plan C. Incident Reports D. 24-hour patient care and acuity charting E. Discharge summary

A, B, C, D, E

Which of the following are basic purposes for an accurate and complete written patient records? Select all that apply A. Sometimes used by government agencies to evaluate patient care B. It is a permanent record for accountability C. It is a legal record of care D. They are perfect sources for business and marketing E. Can be used for research, teaching and data collection

A, B, C, E

Which of the following statements regarding the DARE format of documentation are correct? Select all that apply A. Data, action, response and evaluation, education and patient teaching B. Data is both subjective and objective C. Action combines planning and implementation D. You need to use all the DARE steps each time you make notes on a particular focus E. Response is the same as evaluation and effectiveness F. Some facilities include education or patient teaching

A, B, C, E, F

Which of the following is a typical section of a traditional chart? Select all that apply A. Admission sheet and physician's orders B. Progress notes and nurse's admission information C. History and Physical Examination Data D. Medical Administration Record E. Care plan and nurse's notes

A, B, D, E

What kind of notes are taken when charting by exception? Select all that apply. A. Additional treatments done or planned treatments withheld B. Standing orders and physical history C. New Concerns D. Changes in patient condition

A, C, D

Which of the following formats is included under Charting be exception? Select all that apply. A. PIE B. SOAPE C. SOAPIER D. APIE

A, D

Which of the following statements about home health care are true? Select all that apply A. It provides a narrower scope of people for a wider majority of services. B. Requires a whole health care team to work closely C. Does not demand meticulous and thorough documentation D. Duplication of documentation is difficult to avoid

A. B. D

Which of the following statements are true regarding basic rules for documentation. Select all that apply. A. Use direct quotes for objective assessments B. If a charting error is made, draw one line through the faulty information C. Chart only your own care even when someone else calls you for a late entry. D. Chart after care is provided, as soon as possible, and as often as needed E. Sign each block of charting with full legal initials and title https://i.imgur.com/sCdOvoz.png

B, C, D

Based upon the legal guidelines for documentation, which of the following corrective action is incorrect?

Be certain that entry is factual even when opinions are used

There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with?

CBE

The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:

Diagnosis-related groups

When does discharge planning ideally begin?

During admission

Which of the following statements about FOCUS CHARTING is incorrect?

Focus can be a medical diagnosis

What do you have to fill up when an event transpired is not consistent with routine operation of a health care unit or routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care. These events have the potential to cause injury.

Incident reports

In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included?

Included in the notations under PLANNING

A system used to consolidate patient orders and care needs in a centralized, concise way.

Kardex or Rand System

What kind of documentation is the following? Pain scale 0/10, hand and leg strong to right, weak to left. Skin pink, warm and dry, turgor good, incision to Rt. anterior chest wall erythema or edema ...................Jane Night, LPN.

Narrative

Which of the following is considered a traditional charting?

Narrative

Preprinted guidelines used to care for patients with similar health problems.

Nursing Care Plan

Which of the following statements about documenting is not true?

Nursing documentation can be accepted in both verbal and written form

What is the essential difference between PIE and SOAPE formats?

PIE is from a nursing process. SOAPE is from a medical model

Which of the following should not be considered when filling up an incident report?

Personal assessment and judgment of incident

Active, inactive potential and resolved problems that serve as the index for charting documentation

Problem List

In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?

REVISIONS are noted in the EVALUATION section

Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation

Standardized nursing care plans

Charting that is divided into sections or blocks. Emphasis is placed on specific sections, or sheets of information. It also uses graphics and narrative charting

Traditional Chart

What is the difference between Traditional and Problem Oriented medical Record charting?

Traditional uses an abbreviated story form. POMR uses an outline form