Nursing Health Assessment A Best Practice Approach 1st edition by Jensen
Nursing Health Assessment A Best Practice Approach 1st edition by Jensen
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Chapter 05- Documentation and Interdisciplinary Communication
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
| 1. | The medical record serves many purposes. What are they? (Select all that apply.) | |
| A) | Framework for medical information | |
| B) | Means for financial reimbursement | |
| C) | Research | |
| D) | Care planning | |
| E) | Information for the family | |
| 2. | A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? | |
| A) | To provide a record of the nurse’s activities | |
| B) | To provide a record of the actual events | |
| C) | To provide a record of how the patient was harmed | |
| D) | To provide a record of the physician’s activities | |
| 3. | Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit? | |
| A) | The evaluation of financial reimbursement | |
| B) | The evaluation of patient nutrition | |
| C) | The evaluation of care for continual improvement | |
| D) | The evaluation of timely documentation of pain | |
| 4. | Why do nursing students review medical records? (Select all that apply.) | |
| A) | To enhance clinical learning | |
| B) | To compare nursing care provided to patients | |
| C) | To evaluate the plan of care for a specific patient | |
| D) | To verify that laboratory results are accurate | |
| E) | To better understand complex clinical situations | |
| 5. | The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? | |
| A) | Safety among patient populations decreases | |
| B) | Pharmacy orders are electronically verified | |
| C) | Physician notes are more secure | |
| D) | Patient safety increases | |
Answer Key
| 1. | A, B, C, D |
| 2. | B |
| 3. | C |
| 4. | A, E |
| 5. | D |
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