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 th a.
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b) No litigation can be brought against the person who b. signed.
c) Interventions were implemented to meet the patien c. needs.
d) d. The patient’s response to the intervention was posi
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?
The hospital needs to show that employees care fo a. patients.
Institutions are reimbursed only for patient care tha b.
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
5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway.
ANS: D
Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.
DIF: Cognitive Level: Knowledge REF: Pages OBJ: 8
TOP: Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A
6. What makes home health care documentation unique?
a. Some charting is retained at the hospital.
b. The physician’s office needs separate charting.
c. Different health care providers need access.
d. The physician is the pivotal person in the charting.
ANS: C
Home health care documentation has unique problems because of the need for different health care workers to access the medical record.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 9
TOP: Documentation KEY: Nursing Process Step: N/A
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