Exam (elaborations)
Chapter 3 Documentation
- Course
- Nursing
- Institution
- Western Piedmont Community College
Chapter 3 Documentation
[Show more]
Content preview
Chapter 3: DocumentationMULTIPLE CHOICE
1. What does documentation of type of care, time of care, and signature of the person prove?
a. The person who signed the documentation did all the work noted.
b. No litigation can be brought against the person who signed.
c. Interventions were implemented to meet the patient‘s needs.
d. The patient‘s response to the intervention was positive.
ANS: C
Documenting type of care, time of care, and signature of the person results in recording the
interventions that are implemented to meet the patient‘s needs. Many charting entries include
doctor‘s visits, presence of family, or interventions by other departments. Patient response to
some interventions is not always positive.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38
OBJ: 1 TOP: Documentation
KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A
2. Why is documentation especially significant in managed care?
a. The hospital needs to show that employees care for patients.
b. Institutions are reimbursed only for patient care that is documented.
c. Patients might bring lawsuits if care was not given.
d. Documents may become part of a lawsuit.
ANS: B
Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the
prospective payment system of diagnosis-related groups (DRGs); a system that classifies
patients by age, diagnosis, surgical procedure, and other information with hundreds of
different categories to predict the use of hospital resources, including length of stay, resulting
in a fixed payment amount.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 40
OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. The nurse charts only additional treatments done, changes in patient condition, and new
concerns. What is this system of documentation?
a. SOAP
b. Block
c. CBE
d. Focus
ANS: C
Charting additional treatments done, changes in a patient‘s condition, and new concerns
during the shift is charting by exception (CBE).
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 46
OBJ: 1 | 5 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
, MSC: NCLEX: N/A
4. What form explains the lapse when events are not consistent with facility or national standards
of expected care?
a. Subjective data
b. Focus chart
c. Incident report
d. Nursing assessment
ANS: C
An incident report is completed when patient care was not consistent with facility or national
standards. The form explains the event, time, extent of injury, and who was notified.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 47
OBJ: 1 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. The staff from all disciplines is developing integrated care plans for a projected length of stay
for patients of a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway.
ANS: D
Critical pathways allow staff from all disciplines to develop integrated care plans for a
projected length of stay for patients of a specific case type.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 51
OBJ: 8 TOP: Documentation
KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A
6. What makes home health care documentation unique?
a. Some charting is retained at the hospital.
b. The physician‘s office needs separate charting.
c. Different health care providers need access.
d. The physician is the pivotal person in the charting.
ANS: C
Home health care documentation has unique problems because of the need for different health
care workers to access the medical record.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 53
OBJ: 9 TOP: Documentation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
7. What regulates standards for long-term care documentation?
a. OBRA
b. Title XXII
c. Nursing diagnoses
d. The care plan
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 mentor2000. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
77858 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now