Nurs 371 Exam 1 Questions With Correct Answers
What is documentation? Correct Answer-written or electronic legal
record of all pertinent interactions with the patient--the nursing process
What is the nursing process? Correct Answer-Assessing
Diagnosing
Planning
Implementing
Evaluating
Documentation is a way of _____ to anyone that has access to the chart.
Correct Answer-communication
What are characteristics of effective documentation? Correct Answer--
consistent with professional and agency standards (know policies)
-complete (as events occur)
-accurate (mirror the pt)
-concise (brief, but don't lose the meaning, omit words like a, the)
-factual (correct time, no rounding)
-organized and timely (sequential)
-legally prudent
-confidential (not everyone has right to know, only if caring for pt)
,What confidential? Correct Answer-all information about patients
written on paper, spoken aloud, saved on computer
-named, address, phone, fax, SSN
-reason sick
-assessments and tx
-info about past health conditions
What is breach? Correct Answer-a failure to fullfil a duty or obligation
T or F. Nurse fails to log off a computer after documenting patient care
has breached patient confidentiality. Correct Answer-True
What are the patients right in regards to records? Correct Answer--see
and copy health records
-update
-get list of disclosure
-request restriction on certain use/disclosures (request rights to certain
people)
-choose how to receive health info
T or F. A patient has the right to obtain, review, and revise the patient
information in his or her health record. Correct Answer-false, cannot
revise
,What is included in health records? Correct Answer--identification and
demographic data
-informed consent for tx and procedures
-admission nursing hx
-nursing dx/problems
-nursing/multidisciplinary care plan
-record of nursing care tx and evaluation
-med hx
-med dx
-therapy orders
-medical and health discipline's progress notes
-reports of physical exams
-reports of diagnostic studies
-summary of operative procedures
-discharge plan and summary
Who does the admission history? If not, what happens? Correct Answer-
RN, if LPN does it an RN checks it
When does discharge planning begin? Correct Answer-admission
What is the purpose of patient records? Correct Answer--
communications with other professionals
-record of diagnostic and therapeutic orders and results
, -care planning
-quality process and performance improvement
-research (consent if use identifiers)
-decision analysis (managers use when looking to give raises)
-education
-credentialing, regulation, and legislation
-legal and historical documentation
-reimbursement
-facilitate patient care (effective or not)
-serve as financial and legal record
-help in clinical research (research med or clinical trial eval)
-support decision analysis (tx favorable or not)
What are the guidelines for receiving verbal orders in an emergency?
Correct Answer--record in patient medical record
-read back order to verify
-date and note time order were issued
-record VO, name of physician/NP, followed by nurse's name and title
-registered professional nurse must see that orders are transcribed
according to procedure
How should verbal order be recorded in chart? Correct
Answer-X/XX/XXXX 0550 Draw a CBC at 0600 in am and call results.
V.O. Dr. John Doe/ G. Ringe SLUSN
What is documentation? Correct Answer-written or electronic legal
record of all pertinent interactions with the patient--the nursing process
What is the nursing process? Correct Answer-Assessing
Diagnosing
Planning
Implementing
Evaluating
Documentation is a way of _____ to anyone that has access to the chart.
Correct Answer-communication
What are characteristics of effective documentation? Correct Answer--
consistent with professional and agency standards (know policies)
-complete (as events occur)
-accurate (mirror the pt)
-concise (brief, but don't lose the meaning, omit words like a, the)
-factual (correct time, no rounding)
-organized and timely (sequential)
-legally prudent
-confidential (not everyone has right to know, only if caring for pt)
,What confidential? Correct Answer-all information about patients
written on paper, spoken aloud, saved on computer
-named, address, phone, fax, SSN
-reason sick
-assessments and tx
-info about past health conditions
What is breach? Correct Answer-a failure to fullfil a duty or obligation
T or F. Nurse fails to log off a computer after documenting patient care
has breached patient confidentiality. Correct Answer-True
What are the patients right in regards to records? Correct Answer--see
and copy health records
-update
-get list of disclosure
-request restriction on certain use/disclosures (request rights to certain
people)
-choose how to receive health info
T or F. A patient has the right to obtain, review, and revise the patient
information in his or her health record. Correct Answer-false, cannot
revise
,What is included in health records? Correct Answer--identification and
demographic data
-informed consent for tx and procedures
-admission nursing hx
-nursing dx/problems
-nursing/multidisciplinary care plan
-record of nursing care tx and evaluation
-med hx
-med dx
-therapy orders
-medical and health discipline's progress notes
-reports of physical exams
-reports of diagnostic studies
-summary of operative procedures
-discharge plan and summary
Who does the admission history? If not, what happens? Correct Answer-
RN, if LPN does it an RN checks it
When does discharge planning begin? Correct Answer-admission
What is the purpose of patient records? Correct Answer--
communications with other professionals
-record of diagnostic and therapeutic orders and results
, -care planning
-quality process and performance improvement
-research (consent if use identifiers)
-decision analysis (managers use when looking to give raises)
-education
-credentialing, regulation, and legislation
-legal and historical documentation
-reimbursement
-facilitate patient care (effective or not)
-serve as financial and legal record
-help in clinical research (research med or clinical trial eval)
-support decision analysis (tx favorable or not)
What are the guidelines for receiving verbal orders in an emergency?
Correct Answer--record in patient medical record
-read back order to verify
-date and note time order were issued
-record VO, name of physician/NP, followed by nurse's name and title
-registered professional nurse must see that orders are transcribed
according to procedure
How should verbal order be recorded in chart? Correct
Answer-X/XX/XXXX 0550 Draw a CBC at 0600 in am and call results.
V.O. Dr. John Doe/ G. Ringe SLUSN
