FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLA
FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLA
Exam (elaborations)
FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITION
392 views 0 purchase
Course
FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLA
Institution
FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLA
FUNDAMENTALS
OF NURSING: ACTIVE LEARNING FOR
COLLABORATIVE PRACTICE, 2ND EDITION
FOR MORE MATERIALS-
Chapter 10: Documentation, Electronic Health Records, and Reporting
MULTIPLE CHOICE
1. The nurse understands the need for accurate documentation due to which fact?
a. Accurate documentation i...
fundamentals of nursing active learning for collaborative practice
fundamentals of nursing active learning for collaborative practice
2nd edition for more materials httpswwwfacebo
Written for
FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLA
All documents for this subject (16)
Seller
Follow
BRIGHTERSTUDIES
Reviews received
Content preview
, FUNDAMENTALS
OF NURSING: ACTIVE LEARNING FOR
COLLABORATIVE PRACTICE, 2ND EDITION
,Chapter 10: Documentation, Electronic Health Records, and Reporting
MULTIPLE CHOICE
1. The nurse understands the need for accurate documentation due to which fact?
a. Accurate documentation is needed for proper reimbursement.
b. Accurate documentation must be electronically generated.
c. Accurate documentation does not include e-mails or faxes.
d. Accurate documentation is only accepted in court if written by hand.
ANS: A
Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic- related
groups (DRGs). DRGs are a system used to classify hospital admissions. Health care documentation is any
written or electronically generated information about a patient that describes the patient, the patient’s
health, and the care and services provided, including the dates of care. These records may be paper or
electronic documents, such as electronic medical records, faxes, e-mails, audiotapes, videotapes, and
images. All such records are considered legal documentation and may be used in court.
DIF: Remembering OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT:
Concepts: Communication
2. The nurse identifies which statement to be true regarding nursing documentation?
a. Standards for documentation are established by a national commission.
b. Medical records should be accessible to everyone.
c. Documentation should not include the patient’s diagnosis.
d. High-quality nursing documentation reflects the nursing process.
ANS: D
The ANA’s model for high-quality nursing documentation reflects the nursing process and includes
accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability. Standards
for documentation are established by each health care organization’s policies and procedures. They
should be in agreement with The Joint Commission’s standards and elements of performance, including
having a medical record for each patient that is accessed only by authorized personnel. General
principles of medical record documentation from the Centers for Medicare and Medicaid Services (2017)
include the need for completeness and legibility; the reasons for each patient encounter, including
assessments and diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis
and treatment.
FOR MORE MATERIALS- https://www.facebook.com/kris.stuvia.35
, DIF: Understanding OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT:
Concepts: Communication
3. The nurse identifies which true statement regarding the medical record?
a. It serves as a major communication tool but is not a legal document.
b. It cannot be used to assess quality of care issues.
c. It is not used to determine reimbursement claims.
d. It can be used as a tool for biomedical research and provide education.
ANS: D
The medical record promotes continuity of care and ensures that patients receive appropriate health
care services. The record can be used to assess quality-of-care measures, determine the medical
necessity of health care services, support reimbursement claims, and protect health care providers,
patients, and others in legal matters. It is a clinical data archive. The medical record serves as a tool for
biomedical research and provider education, collection of statistical data for government and other
agencies, maintenance of compliance with external regulatory bodies, and establishment of policies and
regulations for standards of care. The record serves as the major communication tool between staff
members and as a single data access point for everyone involved in the patient’s care. It is a legal
document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and
authenticity. The record can be used to assess quality-of-care measures, determine the medical
necessity of health care services, support reimbursement claims, and protect health care providers,
patients, and others in legal matters.
DIF: Understanding OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT:
Concepts: Communication
4. The nurse knows that paper records are being replaced by other forms of record keeping for
what reason?
a. Paper is fragile and susceptible to damage.
b. Paper records are always available to multiple people at a time.
c. Paper records can be stored without difficulty and are easily retrievable.
FOR MORE MATERIALS- https://www.facebook.com/kris.stuvia.35
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller BRIGHTERSTUDIES. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $16.49. You're not tied to anything after your purchase.
