CHAPTER 13: DOCUMENTATION AND INFORMATICS

CHAPTER 13: DOCUMENTATION AND INFORMATICS

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. While documenting on a client’s medical record, the nurse realizes that it is a legal document and should include all of the following, EXCEPT:

ANS:  D

The legal issues of documentation require legible and neat writing on paper records, the proper use of spelling and grammar, the use of authorized abbreviations, and documentation that is factual and time sequenced. Documentation in a client’s medical record does not need to be typed.

PTS:   1                    DIF:    Application    REF:   Legal and Practice Standards

2. The nurse who forgets to document an element of clinical significance and recalls it later should:

ANS:  D

When the nurse forgets to document significant data, it is appropriate and advisable to include this data at a later date. The data should include a date and signature. The other choices are incorrect and should not be done.

PTS:   1                    DIF:    Application    REF:   Organization

3. The nurse notes a significant change in the client’s condition. The nurse should:

ANS:  A

The nurse should notify the physician of any change in a client’s condition and document the client’s change and the notification of the physician in the client’s chart. The nurse should not only document the change in the chart or only notify the physician and chart that the physician was notified. The nurse does not need to notify the nursing supervisor with a change in a client’s condition.

PTS:   1                    DIF:    Application    REF:   General Documentation Guidelines

4. The nurse is attending an in-service education program that identifies the Joint Commission’s requirements of documentation. Which of the following would be one of these requirements?

ANS:  C

The Joint Commission requires: 1) the involvement of the client in the development of the plan of care, which must be documented in the medical record, and 2) that interdisciplinary planning and implementation of all aspects of care occur. The other choices are not requirements by the Joint Commission regarding documentation.

PTS:   1                    DIF:    Analysis

REF:   The Joint Commission on Accreditation of Healthcare Organizations (TJC)