Fundamentals of Nursing- Ch.3 Documentation

Question 1

Use of a fax machine to send medical information about a patient is prohibited.

Accepted Answer

false

Question 2

form explaining lapse when events are not consistent with facility/national standards of care

Accepted Answer

Incident report

Question 3

Put quotation marks around the subjective statements when charting in SOAPE format

Accepted Answer

true

Question 4

What should a medical record provide for all health care providers?

Accepted Answer

A patient's nursing problems, Care given to the patient, The patient's response to treatment

Question 5

What regulates standards for long-term care documentation?

Accepted Answer

OBRA

Question 6

The process used to appraise the practice of an individual nurse is?

Accepted Answer

Peer review

Question 7

What are the basic purposes of written patient records?

Accepted Answer

Legal record of care, Teaching, written communication

Question 8

The nursing note that's in paragraph form & chronologically "tells a story" is a narrative note

Accepted Answer

true

Question 9

Endocarditis is an

Accepted Answer

inflammation of the inner layer of the heart

Question 10

chart additional treatments done/Changes in patient condition/new concerns.What is this called?

Accepted Answer

CBE

Question 11

Postprandial means

Accepted Answer

after a meal

Question 12

Rhinoplasty is

Accepted Answer

a surgical repair of the nose

Question 13

What's required to do to adhere to confidentiality for the pts. medical record?

Accepted Answer

Have a clinical reason for reading the record

Question 14

A new pt. is admitted to long term care;who has responsibilty for pts. history, & care plan?

Accepted Answer

Registered Nurse

Question 15

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

Accepted Answer

Interventions were implemented to meet the patient's needs.

Question 16

Leukopenia means

Accepted Answer

a decrease or deficiency in the number of white blood cells

Question 17

When staff makes integrated care plans for a length of stay for Pts. of specific case type is ?

Accepted Answer

critical pathway

Question 18

With digital documentation, what should you do to make sure no one alters the info you entered?

Accepted Answer

Logging off

Question 19

What will the nurse implement when an documentation error is made in pts. chart?

Accepted Answer

Draw a single line through the error

Question 20

basic word elements used in medical terminology are prefix, word root, suffix &combining form

Accepted Answer

true

Question 21

Who is the legal owner of the patient's medical record?

Accepted Answer

Institution

Question 22

When a patient refuses care it is unnecessary to document care because you didn't provide care.

Accepted Answer

false

Question 23

Hepatomegaly is

Accepted Answer

enlargement of the liver

Question 24

What is the documentation format that uses the acronym SOAPE?

Accepted Answer

Problem-oriented

Question 25

When giving pain meds, you must also chart the patient's response to the pain meds.

Accepted Answer

true

Question 26

What is the purpose of QA (quality assurance)?

Accepted Answer

To evaluate care results against accepted standards

Question 27

What are categories of inadequate documentation that may lead to a malpractice claim?

Accepted Answer

incorrectly recording the time of an event, documenting an incorrect date, failing to record verbal orders

Question 28

Lithotripsy is a procedure to

Accepted Answer

crush or remove a calculus or stone

Question 29

What makes some home health care documentation unique?

Accepted Answer

Different health care providers need access

Question 30

What does the nurse use as a basis for documentation in focus charting?

Accepted Answer

Nursing diagnoses

Fundamentals of Nursing- Ch.3 Documentation

Questions 30

Fundamentals of Nursing- Ch.3 Documentation

Questions 30