Chapter 17- Documentation

12. What is the primary purpose of the patient record? A) communication B) Advocacy C) Research D) Education

ANS: A A) communication

24. A nurse uses informatics to plan nursing care for a patient. Which three terms best describes this science as it is applied to nursing? A) data, information, knowledge B) process, documentation, analysis C) research, controls, variables D) hypothesis, nursing, practice

ANS: A A) data, information, knowledge

22. What is the primary purpose of an incident report? A) means of identifying risks B) basis for staff evaluation C) basis for disciplinary action D) format for audiotaped report

ANS: A A) means of identifying risks

14. Which one of the following methods of documentation is organized around patient diagnoses rather than around patient information? A) problem-oriented medical record (POMR) B) source-oriented record C) PIE charting system D) focus charting

ANS: A A) problem-oriented medical record (POMR)

6. A student has reviewed a patient's chart before beginning assigned care. Which of the following actions violates patient confidentiality? A) writing the patient's name on the student care plan B) providing the instructor with plans for care C) discussing the medications with a unit nurse D) providing information to the physician about laboratory data

ANS: A A) writing the patient's name on the student care plan

7. Which of the following are examples of breaches of patient confidentiality? Select all that apply. A) A nurse discusses a patient with a coworker in the elevator. B) A nurse shares her computer password with a relative of a patient. C) A nurse checks the medical record of a patient to see who should be called in an emergency. D) A nurse updates the employer of a patient regarding the patient's return to work. E) A nurse uses a computer to document a patient's response to pain medication. F) A head nurse accesses the medical records of a nurse on her shift to check her condition.

ANS: A B D F A) A nurse discusses a patient with a coworker in the elevator. B) A nurse shares her computer password with a relative of a patient. D) A nurse updates the employer of a patient regarding the patient's return to work. F) A head nurse accesses the medical records of a nurse on her shift to check her condition.

18. Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply. A) patient sex B) patient admission date C) patient physical assessment D) patient insurance E) patient history F) patient ethnicity

ANS: A B D F A) patient sex B) patient admission date D) patient insurance F) patient ethnicity

8. Which of the following are examples of incidental disclosures of patient health information that are permitted? Select all that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming patients. B) Two nurses are overheard talking about a patient through the door of an empty patient room. C) A nurse places a patient chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a patient who is seated in the waiting room. F) A nurse leaves a reminder for an appointment on a patient's answering machine along with the results of lab work.

ANS: A B E A) A nurse working in a physician's office puts out a sign-in sheet for incoming patients. B) Two nurses are overheard talking about a patient through the door of an empty patient room. E) A nurse calls out the name of a patient who is seated in the waiting room.

11. Which of the following abbreviations are on the list of the Joint Commission "do not use" abbreviations? Select all that apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than) F) mcg (micrograms)

ANS: A B E A) U (unit) B) QD (daily) E) > (greater than)

4. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

ANS: B B) A. Jones, RN

17. Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse? A) problem-oriented medical record B) charting by exception C) PIE charting system D) focus charting

ANS: B B) charting by exception

10. A physician's order reads "up ad lib." What does this mean in terms of patient activity? A) may walk twice a day B) may be up as desired C) may only go to the bathroom D) must remain on bed rest

ANS: B B) may be up as desired

21. A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) minimum data set C) OASIS D) charting by exception

ANS: B B) minimum data set

16. A nurse organizes patient data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) patient complaints of pain B) patient symptoms C) patient's chief complaint D) patient interventions

ANS: B B) patient symptoms

13. In what type of documentation method would a nurse document narrative notes in a nursing section? A) problem-oriented medical record B) source-oriented record C) PIE charting system D) focus charting

ANS: B B) source-oriented record

5. In which of the following cases should a progress note be written? Select all that apply. A) for any nurse-patient interaction B) when admitting a patient C) when receiving a patient postoperatively D) when assisting a patient with ADLs E) when a procedure is performed F) when a patient sends back an untouched dinner tray

ANS: B - C - E B) when admitting a patient C) when receiving a patient postoperatively E) when a procedure is performed

3. Which of the following data entries follows the recommended guidelines for documenting data? A) "Patient is overwhelmed by the diagnosis of pancreatic cancer." B) "Patient kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Patient complained about the quality of the nursing care provided on previous shift."

ANS: C C) "Following oxygen administration, vital signs returned to baseline."

9. A patient asks to see his medical record (chart). How would the nurse respond? A) "I can't let you do that without a doctor's order." B) "Our hospital policy is that you can't do that." C) "I will get your chart and provide you with privacy to read it." D) "Why would you want to do that? It will only make you worry."

ANS: C C) "I will get your chart and provide you with privacy to read it."

19. A nurse has access to computerized standardized plans of care. After printing one for a patient, what must be done next? A) Date it and put it in the patient's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific patient. D) Use it as printed, based on common needs.

ANS: C C) Individualize it to the specific patient.

15. What is the primary purpose of focus charting? A) nursing diagnoses B) medical problems C) patient concerns D) expected outcomes

ANS: C C) patient concerns

1. What is the nurse's best defense if a patient alleges nursing negligence? A) testimony of other nurses B) testimony of expert witnesses C) patient's record D) patient's family

ANS: C C) patient's record

2. A nurse is documenting the intensity of a patient's pain. What would be the most accurate entry? A) "Patient complaining of severe pain." B) "Patient appears to be in a lot of pain and is crying." C) "Patient states has pain; walking in hall with ease." D) "Patient states pain is a 9 on a scale of 1 to 10."

ANS: D D) "Patient states pain is a 9 on a scale of 1 to 10."

20. What part of the patient's record is commonly used to document specific patient variables, such as vital signs? A) progress notes B) nursing notes C) critical paths D) graphic record

ANS: D D) graphic record

23. A group of nurses visits selected patients individually at the beginning of each shift. What are these procedures called? A) nursing care conferences B) staff visits C) interdisciplinary referrals D) nursing care rounds

ANS: D D) nursing care rounds