NRS 101 Exam 1 Questions With Correct
Answers
Nurses |are |responsible |for |protecting |records |from |- |CORRECT |ANSWER✔✔-all |unauthorized |
readers
Confidential |permanent |legal |document |- |CORRECT |ANSWER✔✔-Records |or |chart
Oral, |written, |or |audiotaped |exchange |of |information |- |CORRECT |ANSWER✔✔-Reports
Team |members |communicating |in |a |group |- |CORRECT |ANSWER✔✔-Conferences
A |professional |caregiver |giving |formal |advice |to |another |caregiver |- |CORRECT |ANSWER✔✔-
Consultations
Arrangement |for |services |by |another |care |provider |- |CORRECT |ANSWER✔✔-Referrals
Purposes |of |Records |- |CORRECT |ANSWER✔✔-Communication
Legal |documentation
Reimbursement
Education
Research
Auditing/monitoring
What |is |the |correct |method |for |correcting |an |error |in |a |paper |record |- |CORRECT |ANSWER✔✔-
Draw |a |single |line |through |the |error, |write |the |word |"error" |above |it, |sign |your |initials, |and |
date |it.
,Guidelines |for |Quality |Documentation |and |Reporting |- |CORRECT |ANSWER✔✔-Factual
Accurate
Complete
Current |
Organized
Key |information |may |be |lost |from |one |episode |of |care |to |the |next. |- |CORRECT |ANSWER✔✔-
Paper |record
A |digital |version |of |a |patient's |medical |record
Integrates |all |of |a |patient's |information |in |one |record
Improves |continuity |of |care |- |CORRECT |ANSWER✔✔-Electronic |health |record |(EHR)
Methods |of |Recording |- |CORRECT |ANSWER✔✔-Narrative |and |Problem-oriented |medical |
record
Methods |of |Recording: |
Progress |Notes |- |CORRECT |ANSWER✔✔-SOAP, |SOAPIE, |PIE, |FOCUS |CHARTING
Subjective, |objective, |assessment, |plan |- |CORRECT |ANSWER✔✔-SOAP
Subjective, |objective, |assessment, |plan, |intervention, |evaluation |- |CORRECT |ANSWER✔✔-
SOAPIE
Problem, |intervention, |evaluation |- |CORRECT |ANSWER✔✔-PIE
, Data, |action, |response |- |CORRECT |ANSWER✔✔-Focus |charting |(DAR)
Focuses |on |documenting |deviations |- |CORRECT |ANSWER✔✔-Charting |by |exception |(CBE)
Incorporate |a |multidisciplinary |approach |to |care |- |CORRECT |ANSWER✔✔-Case |management |
plan |and |critical |pathways
Guides |the |nurse |through |a |complete |assessment |to |identify |relevant |nursing |diagnoses |or |
problems |- |CORRECT |ANSWER✔✔-Admission |nursing |history |form
Help |team |members |quickly |see |patient |trends |over |time |and |decrease |time |spent |on |writing |
narrative |notes |- |CORRECT |ANSWER✔✔-Flow |sheets |and |graphic |records
A |portable |"flip-over" |file |or |notebook |with |patient |information |- |CORRECT |ANSWER✔✔-
Patient |care |summary |or |Kardex
Preprinted, |established |guidelines |used |to |care |for |patients |who |have |similar |health |problems
|- |CORRECT |ANSWER✔✔-Standardized |care |plans
common |record |keeping |forms |- |CORRECT |ANSWER✔✔-Standardized |care |plans
Discharge |summary |forms
Acuity |records
the |quality |control |and |justification |for |reimbursement |from |Medicare, |Medicaid, |or |private |
insurance. |- |CORRECT |ANSWER✔✔-Documentation
Occurs |with |transfer |of |patient |care
Provides |continuity |and |individualized |care
Answers
Nurses |are |responsible |for |protecting |records |from |- |CORRECT |ANSWER✔✔-all |unauthorized |
readers
Confidential |permanent |legal |document |- |CORRECT |ANSWER✔✔-Records |or |chart
Oral, |written, |or |audiotaped |exchange |of |information |- |CORRECT |ANSWER✔✔-Reports
Team |members |communicating |in |a |group |- |CORRECT |ANSWER✔✔-Conferences
A |professional |caregiver |giving |formal |advice |to |another |caregiver |- |CORRECT |ANSWER✔✔-
Consultations
Arrangement |for |services |by |another |care |provider |- |CORRECT |ANSWER✔✔-Referrals
Purposes |of |Records |- |CORRECT |ANSWER✔✔-Communication
Legal |documentation
Reimbursement
Education
Research
Auditing/monitoring
What |is |the |correct |method |for |correcting |an |error |in |a |paper |record |- |CORRECT |ANSWER✔✔-
Draw |a |single |line |through |the |error, |write |the |word |"error" |above |it, |sign |your |initials, |and |
date |it.
,Guidelines |for |Quality |Documentation |and |Reporting |- |CORRECT |ANSWER✔✔-Factual
Accurate
Complete
Current |
Organized
Key |information |may |be |lost |from |one |episode |of |care |to |the |next. |- |CORRECT |ANSWER✔✔-
Paper |record
A |digital |version |of |a |patient's |medical |record
Integrates |all |of |a |patient's |information |in |one |record
Improves |continuity |of |care |- |CORRECT |ANSWER✔✔-Electronic |health |record |(EHR)
Methods |of |Recording |- |CORRECT |ANSWER✔✔-Narrative |and |Problem-oriented |medical |
record
Methods |of |Recording: |
Progress |Notes |- |CORRECT |ANSWER✔✔-SOAP, |SOAPIE, |PIE, |FOCUS |CHARTING
Subjective, |objective, |assessment, |plan |- |CORRECT |ANSWER✔✔-SOAP
Subjective, |objective, |assessment, |plan, |intervention, |evaluation |- |CORRECT |ANSWER✔✔-
SOAPIE
Problem, |intervention, |evaluation |- |CORRECT |ANSWER✔✔-PIE
, Data, |action, |response |- |CORRECT |ANSWER✔✔-Focus |charting |(DAR)
Focuses |on |documenting |deviations |- |CORRECT |ANSWER✔✔-Charting |by |exception |(CBE)
Incorporate |a |multidisciplinary |approach |to |care |- |CORRECT |ANSWER✔✔-Case |management |
plan |and |critical |pathways
Guides |the |nurse |through |a |complete |assessment |to |identify |relevant |nursing |diagnoses |or |
problems |- |CORRECT |ANSWER✔✔-Admission |nursing |history |form
Help |team |members |quickly |see |patient |trends |over |time |and |decrease |time |spent |on |writing |
narrative |notes |- |CORRECT |ANSWER✔✔-Flow |sheets |and |graphic |records
A |portable |"flip-over" |file |or |notebook |with |patient |information |- |CORRECT |ANSWER✔✔-
Patient |care |summary |or |Kardex
Preprinted, |established |guidelines |used |to |care |for |patients |who |have |similar |health |problems
|- |CORRECT |ANSWER✔✔-Standardized |care |plans
common |record |keeping |forms |- |CORRECT |ANSWER✔✔-Standardized |care |plans
Discharge |summary |forms
Acuity |records
the |quality |control |and |justification |for |reimbursement |from |Medicare, |Medicaid, |or |private |
insurance. |- |CORRECT |ANSWER✔✔-Documentation
Occurs |with |transfer |of |patient |care
Provides |continuity |and |individualized |care
