ATI Documentation

A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations form an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? A. Charting by exception. B. Subjective, objective, assessment, plan format. C. Problem, intervention, evaluation model. D. Data, action, response charting.

A. Charting by exception.

A charge nurse is reviewing characteristics of electronic documentation with staff as a provider's office. Which fo the following characteristics should the charge nurse plan to include? (Select all that apply) A. Reduces medical errors. B. Improves listening skills among interdisciplinary team members. C. Less convenient that paper-based charting. D. Makes clients medical history more easily available. E. Increases accuracy of coding procedures.

A. Reduces medical errors. D. Makes clients medical history more easily available. E. Increases accuracy of coding procedures.

A nurse manager is reviewing the documentation of four newly licensed nurses. Which fo the following medication enteries should the nurse identify as being written correctly? A. Synthroig 100 mg PO every morning ac B. Enoxaparin 75 mg SQ bid C. Digoxin 0.25 mg PO qd D. Metformin 500.0 mg PO with every meal.

A. Synthroig 100 mg PO every morning ac

A nurse is discussing computerized provider order entery (CPOE) systems with staff. Which fo the following statements from a staff member indicates an understanding of a CPOE system? A. "CPOE systems are associated with a slightly high error rate." B. "CPOE use does not include medication prescriptions." C. "CPOE systems can increase the speed of care delivery." D. "CPOE use is mandated by HIPPA under the Privacy Rule."

C. "CPOE systems can increase the speed of care delivery."

A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart enteries should the nurse include as an example of objective data? A. The client states, "I've had abdominal pain for the last 3 days." B. The client reports consuming about 1,500 mL of water per day. C. Rebound tenderness noted in RLQ of the abdomen. D. Recommend client referral to a registered dietitian.

C. Rebound tenderness noted in RLQ of the abdomen.

A nurse is talking with a client about their electronic health record (EHR) at the facility. Which fo the following client statements indicates and understanding of EHRs? A. "I will be able to track my health information." B. "My personal information will be entered into a national database." C. "I will have one EHR that will encompass the health care I've received over my lifetime." D. "The goal of EHR is to improve insurance coding."

A. "I will be able to track my health information."

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? A. By mouth B. Intramuscularly C. Per rectum D. Intravenously

A. By mouth

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? A. Immunization data B. Record of client health care payments C. Complete medical information for household members D. Faclility policies

A. Immunization data

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? (Select all that apply) A. MSO4 B. IU C. PO D. qhs E. NKA

A. MSO4 B. IU D. qhs

A nurse in a clinic is reviewing a client's prescription prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? A. PRN B. NPO C. AC D. Ad lib

A. PRN

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which fo the following agencies advocated for nationwide use of EHRs? A. The Institute of Medicine. B. Department of Veteran Affairs. C. American Hospital Association. D. The Joint Commission.

A. The Institute of Medicine.

A nurse is caring for a client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent form the client first? (Select all that apply) A. The admitting provider. B. The charge nurse of the unit. C. The client's sibling. D. The client. E. The client's spiritual advisor.

A. The admitting provider. B. The charge nurse of the unit. D. The client.

A nurse is taking an admission history form a client who is concerned about the facility using an electronic system. Which of the following information should the nurse include as a benefit of electronic documentation? A. The system alerts providers of possible actions that could cause the client harm. B. An electronic system prevents breachers of confidentiality of client data. C. Providers can document client information in the electronic record during system downtime. D. System encryption eliminates the need for security firewalls.

A. The system alerts providers of possible actions that could cause the client harm.

A staff nurse if evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information? A. "I can take a telephone prescription if a provider is making routine rounds in another area of the facility." B. "I can take a telephone prescription if a provider is directing a code for an unresponsive client." C. "If a client requires an over-the-counter medicatoin for relief of nausea, it is okay to accept a telephone prescription." D. "If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription."

B. "I can take a telephone prescription if a provider is directing a code for an unresponsive client."

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following enteries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? A. "The client is now asleep, and ate most of their breakfast a few hours ago." B. "The client vomited 240mL of clear emesis but denies pain or nausea." C. "The client reports not feeling good, but they look fine." D. "The client has 8 to 10 sores on their body."

B. "The client vomited 240mL of clear emesis but denies pain or nausea."

A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include? A. Providers designate to other staff which abbreviations cannot be used. B. A nurse who delegates a task to an AP will review the charting for that task. C. Providers read and cosign nursing documentation for accuracy. D. Licensed personnel should document out-of-range vital signs for AP.

B. A nurse who delegates a task to an AP will review the charting for that task.

A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? A. The "I" in PIE. B. The "S" in SOAP. C. The "R" in DAR. D. The "E" in PIE.

B. The "S" in SOAP.

A nurse is preparing an in-service about HIPPA. Which of the following information shoudl the nurse plan to include? A. "Accessing the medical record of cients on units other than where you are assigned is allowed." B. "There are large financial penalties for charting vital signs you obtain form another nurse's client." C. "Personnel can be terminated for breaching a client's confidentiality." D. "Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."

C. "Personnel can be terminated for breaching a client's confidentiality."

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? A. A problem-oriented medical record is created using the PIE model for documentation entries. B. A problem-oriented medical record contains seperate sections for laboratory and diagnostic information. C. A problem-oriented medical record promotes information sharing among members of the interdisciplinary team. D. A problem-oriented medical record is rarely used in acute care settings.

C. A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? A. American Nurse Association (ANA) standards prevent client records form being used for legal proceedings. B. HIPAA regulations vary from one state to another. C. Privacy regulations apply to electronic data transfer rather than verbal communication. D. Facilities can establish their own rules for documentation methods.

D. Facilities can establish their own rules for documentation methods.