Chapter 3: Documentation

Chapter 3: Documentation

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. What does documentation of type of care, time of care, and signature of the person prove?

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

Documenting type of care, time of care, and signature of the person 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: Comprehension     REF:   Page               OBJ:   1

TOP:   Documentation                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

2. Why is documentation especially significant in managed care?

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

Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.

 

DIF:    Cognitive Level: Comprehension     REF:   Page               OBJ:   1

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

MSC:  NCLEX: N/A

 

3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?

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: Comprehension     REF:   Page 145        OBJ:   1| 5| 7

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

MSC:  NCLEX: N/A

 

4. What form explains the lapse when events are not consistent with facility or national standards of expected care?

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: Knowledge            REF:   Page               OBJ:   1| 7

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

MSC:   NCLEX: N/A