Chapter 10: Healthcare Team
Communication: Documenting and
Reporting
1. When the nurse recognizes that he has documented one patients
assessment data on the wrong patients medical record, the nurse should
a. Draw a single line through the error, and initial it
b. Use a felt tip pen to cover the error
c. Use white out to cover the error
d. Replace the record, rewriting the error
CORRECT ANSWER: A
Feedback:
When an error occurs, draw a single line through the error and place
your initial above it.
2. Which of the following principles should guide the nurses documentation
of entries on the patients medical record?
a. Nurses may not document for another health professional.
b. Documentation does not includ e photographs.
c. Precise measurements are preferred over approximations.
d. Nurses should not refer to the names of physicians.
CORRECT ANSWER: C
, Feedback:
Precise measurements and times must be used whenever possible.
3. How can the nurse researcher obta in information from a patient record?
a. Audit discharge records
b. Interview nursing staff
c. Examine institutional procedures
d. Study patient records
CORRECT ANSWER: D
Feedback:
Nursing and healthcare research is often carried out by studying patient
records.
4. Besides being an instrument of continuous patient care, the patients
medical record also serves as a(an)
a. Assessment tool
b. Legal document
c. Kardex
d. Incident report
CORRECT ANSWER: B
Feedback:
The patient record serves as a legal document of the p atients health
status and care received.
Communication: Documenting and
Reporting
1. When the nurse recognizes that he has documented one patients
assessment data on the wrong patients medical record, the nurse should
a. Draw a single line through the error, and initial it
b. Use a felt tip pen to cover the error
c. Use white out to cover the error
d. Replace the record, rewriting the error
CORRECT ANSWER: A
Feedback:
When an error occurs, draw a single line through the error and place
your initial above it.
2. Which of the following principles should guide the nurses documentation
of entries on the patients medical record?
a. Nurses may not document for another health professional.
b. Documentation does not includ e photographs.
c. Precise measurements are preferred over approximations.
d. Nurses should not refer to the names of physicians.
CORRECT ANSWER: C
, Feedback:
Precise measurements and times must be used whenever possible.
3. How can the nurse researcher obta in information from a patient record?
a. Audit discharge records
b. Interview nursing staff
c. Examine institutional procedures
d. Study patient records
CORRECT ANSWER: D
Feedback:
Nursing and healthcare research is often carried out by studying patient
records.
4. Besides being an instrument of continuous patient care, the patients
medical record also serves as a(an)
a. Assessment tool
b. Legal document
c. Kardex
d. Incident report
CORRECT ANSWER: B
Feedback:
The patient record serves as a legal document of the p atients health
status and care received.
