Chapter 10: Documentation, Electronic Health Records, and Reporting

Chapter 10: Documentation, Electronic Health Records, and Reporting

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. Accurate documentation by the nurse is necessary since proper documentation:

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.

DIF:    Remembering                                 REF:   p. 130             OBJ:   10.01

TOP:   Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

2. Which of the following is true regarding nursing documentation?

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 (2010) 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.

DIF:    Understanding                                 REF:   p. 130             OBJ:   10.02

TOP:   Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

3. The medical record:

ANS:  D

The medical record 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                                 REF:   p. 130             OBJ:   10.02

TOP:   Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication

4. Paper records are being replaced by other forms of record keeping because:

ANS:  A

Paper records have several potential problems. Paper is fragile, susceptible to damage, and can degrade over time. It may be difficult to locate a particular chart because it is being used by someone else, it is in a different department, or it is misfiled. Storage and control of paper records can be a major problem.

DIF:    Evaluating      REF:   pp. 130-131    OBJ:   10.02             TOP:   Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Communication