Nursing 110 Exam 3 Practice Questions
With All Correct Answers.
How is documentation utilized? - Answer Communicates patient progress, needs, complications, and
tolerance of treatments; used in hospital, legal system, hospital reimbursement, research, quality
improvement, and core measures
Why should there never be blank spaces in a patient chart? - Answer Blank space could easily filled in
with insufficient and falsified data from someone unauthorized
How do we eliminate blank spaces in patient chart? - Answer Draw single line to end of paper
List some tips for charting - Answer Patient is understood client- no need to restate, keep correct time
sequence, when charting subjective data you can put in quotation marks, chart presence of visitors and
doctor's rounds, always follow up with interventions from abnormal assessments, only chart what you
see and do, do not chart your opinion (patient appears...), avoid generalities, don't repeat patient's
history, avoid abbreviations if unsure, no need to chart every step of standardized procedures, only chart
PRN medications- not routine, and DO NOT chart incident report
What should you do if you make a mistake on a handwritten chart? - Answer Draw a single line through
the mistake, initial, and record correct information
*you may indicate that there was a mistake but not needed
What is documentation? - Answer Anything written or printed on which you reply as record or proof of
patient actions and activities
What is accreditation? - Answer Process whereby a professional association or nongovernmental
agency grants recognition to a school or institution for demonstrated ability to meet predetermined
criteria
List components of all health care records - Answer Patient identification and demographic data,
informed consent for treatment and procedures, admission data, nursing diagnoses and care plan,
evaluation of care plan, medical history, medical diagnoses, therapeutic orders, progress notes, physical
,assessment findings, diagnostic study results, patient education, summary of operative procedures, and
discharge plan and summary
What are consultations? - Answer Another form of discussion in which one professional caregiver gives
formal advice about the care of a patient to another caregiver
What are referrals? - Answer An arrangement for services by another care provider
What are diagnosis-related groups (DRGs)? - Answer Classification based on patients' medical
diagnoses
What is an electronic health record (EHR)? - Answer Electronic record of patient health information
generated whenever a patient accesses medical care in any health care delivery setting
What is an electronic medical record (EMR)? - Answer Contains patient data gathered in a health care
setting at a specific time and place and is a part of the EHR
What is a problem-oriented medical record (POMR)? - Answer Method of documentation that
emphasizes patients' problems
What is SOAP? - Answer Subjective, Objective, Assessment, Plan
What is PIE? - Answer Problem, Intervention, Evaluation
What is DAR? - Answer Data, Action, Response
What is focus charting? - Answer Charting methodology for structuring progress notes according to the
focus of the note
What is a source record? - Answer Organization of a patient's chart so each discipline has a separate
section in which to record data
,What is charting by exception (CBE)? - Answer Focuses on documenting deviations from established
norms
What is included in an admission sheet? - Answer Specific demographic data about patient
What is included in a physician's order sheet? - Answer Record of physician's or other health care
provider's orders for treatment and medications with date, time, and signature
What is included in a nurse's admission assessment? - Answer Summary of nursing history and physical
examination
What is included in a graphic sheet and flow sheet? - Answer Record of repeated observations and
measurements such as vital signs, daily weights, and intake and output
What is included in medical history and examination? - Answer Results of initial examination
performed by physician, including findings, family history, confirmed diagnosis, and medical plan of care
What is included in nurses' notes? - Answer Narrative record of nursing process
What is included in medication records? - Answer Accurate documentation of all medication
administered to patient: date, time, route, and nurse's signature
What is included in progress notes? - Answer Ongoing record if patient's progress and response to
medical therapy and review of disease process
What is included in a discharge summary? - Answer Summary of patient's condition, progress,
prognosis, rehabilitation, and teaching needs at a time of dismissal from hospital or health care agency
What is case management? - Answer Model of delivering care that incorporates an interdisciplinary
approach to documenting patient care
What are critical pathways? - Answer Interdisciplinary care plans that include patient problems
, What are variances? - Answer Unexpected outcomes, unmet goals, and interventions not specified
within the critical pathway
What are flow sheets? - Answer Documents on which frequent observations or specific measurements
are recorded
What is a kardex? - Answer Card-filing system that allows quick reference to the particular need of the
patient for certain aspects of nursing care
What are standardized care plans? - Answer Preprinted established guidelines used to care for patients
who have similar health problems
What are acuity records? - Answer Useful for determining hours of care and staff required for a given
group of patients
What are hand-off reports? - Answer Any time one health care provider transfers care of a patient to
another health care provider
What are incident reports? - Answer Report of any event that is not consistent with the routine
operation of a health care unit or routine care of a patient
What is health informatics? - Answer The application of computer and information science in all basic
and applied biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use, and
communication of health-related data
What is information technology? - Answer Management and processing of information, generally with
the assistance of computers
What are nursing informatics? - Answer Specialty that integrates nursing science, computer science,
and information science to manage and communicate data, information, and knowledge of nursing
practice
