Potter and Perry Fundamentals of Nursing (Ch 26) 2023 questions with 100% complete answers (NCLEX Documentation Questions Comprehensive Set For Fundamentals of Nursing Class)

Potter and Perry Fundamentals of Nursing Ch. 26 NCLEX Documentation Questions Comprehensive Set For Fundamentals of Nursing Class: from NCLEX Fundamentals of Nursing Chapter 26, Chapter 26: Documentation and Informatics, nursing foundations NCLEX practice questions documentation Documentation is: A) Anything written or printed that you rely on as record or proof for authorized persons. B) Lab results for a patient you are taking care of. C) Admission paperwork for billing purposes. D) Instructions from the attending doctor. - ANSWER A A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reviews the patient's medical record. b. The student nurse reads the patient's plan of care. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient - ANSWER ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated. You can review your patients' medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit Accreditation is: A) Certification by the ANA. B) Medicare approval. C) Joint Commission specifies guidelines for documentation. D) Passing the NCLEX. - ANSWER C A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? The nurse completed a a. Report. b. Record. c. Consultation. d. Referral - ANSWER ANS: A Reports are oral, written, or audiotaped exchanges of information among caregivers. A patient's record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care. Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider). Which of the following is correctly charted according to the six guidelines for quality recording? A: "Was depressed today" B:"respirations rapid; lung sounds clear" C:"Had a good day. Up and about in room." D:"Crying. States she does not want visitors to see her like this" - ANSWER D: reason you need to document pt. exact words in quotations when recording subjective data. Explain the new rights for clients related to HIPPA. A) Patient right to leave healthcare facility. B) Patient education on privacy protections C) Patient's right to access their medical records. D) Provider must receive consent from patient before releasing information. E) Recourse options if privacy protections are violated. - ANSWER B, C, D, E Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records? a. The nurse determines the degree to which standards of care are met by reviewing patients' health records. b. The nurse realizes that care not documented in patients' health records still qualifies as care provided. c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records. d. The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment. - ANSWER ANS: A The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, "care not documented is care not provided." The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care The standards of documentation by the Joint Commission require: A) Narrative on how pati