Chapter 26: Recording Information

Chapter 26: Recording Information

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. If information is purposely omitted from the record, you should:

ANS:  C

Any deferred or omitted portion of the patient record requires proper documentation that documents this occurrence, along with a rationale for doing so. Erasures and use of correction fluid are inappropriate methods.

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 616

OBJ:   Integrated process—communication and documentation

MSC:  Physiologic Integrity: Basic Care and Comfort

2. Which part of the information contained in the patient’s record may be used in court?

ANS:  D

Anything that is entered into a patient’s record, in paper or electronic form, is a legal document and can be used in court.

DIF:    Cognitive Level: Remembering (Knowledge)                    REF:   p. 616

OBJ:   Integrated process—communication and documentation

MSC:  Physiologic Integrity: Basic Care and Comfort

3. During the course of the interview, you should:

ANS:  B

During the interviewing process, it is important to maintain eye contact with the patient and to spend as little time as possible looking at your notes, so brief written notes are more practical. Later you can go back and formulate a well-versed history by linking all the pieces together.

DIF:    Cognitive Level: Applying (Application)                           REF:   p. 616

OBJ:   Integrated process—communication and documentation

MSC:  Physiologic Integrity: Basic Care and Comfort

4. Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S’s loss of appetite, it would be better to:

ANS:  C

It is best to document what you observe and what is said by the patient rather than documenting your interpretation. Listening and quoting exactly what the patient says is the better rule to follow.

DIF:    Cognitive Level: Applying (Application)                           REF:   p. 621

OBJ:   Integrated process—communication and documentation

MSC:  Physiologic Integrity: Basic Care and Comfort

5. Subjective and symptomatic data are:

ANS:  C

Subjective data, as well as symptomatic data, should be placed in the history section.

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 621

OBJ:   Integrated process—communication and documentation

MSC:  Physiologic Integrity: Basic Care and Comfort