Chapter 07: Documentation

Chapter 07: Documentation

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. Documentation of type of care, time of care, and signature of the person who is documenting proves that:

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

This information 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.

 

DIF:    Cognitive Level: Application             REF:    Page 138         OBJ:    6

TOP:    Documentation                                   KEY:   Nursing Process Step: Implementation

MSC:   NCLEX: N/A

 

2. In managed care, documentation is especially significant because:

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

Institutions are reimbursed only for patient care that is documented.

 

DIF:    Cognitive Level: Application             REF:    Page 139         OBJ:    5

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

3. When the nurse charts only additional treatments done, changes in patient condition, and new concerns, the system of documentation is:

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).

 

DIF:    Cognitive Level: Application             REF:    Page 145         OBJ:    7

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

4. When events are not consistent with facility or national standards of expected care, the form that explains the lapse is the:

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.

 

DIF:    Cognitive Level: Application             REF:    Page 145         OBJ:    6

TOP:    Documentation                                   KEY:   Nursing Process Step: N/A

MSC:   NCLEX: N/A

 

5. When staff from all disciplines develop integrated care plans for a projected length of stay for patients of a specific case type, it 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.

 

DIF:    Cognitive Level: Application             REF:    Pages 150-151

OBJ:    11                    TOP:    Documentation

KEY:   Nursing Process Step: Implementation                                  MSC:   NCLEX: N/A