NRSG 100 Fundamentals Exam 2 Questions
Answers
How cdo chealthcare cproviders cuse cdocumentation? c- cCORRECT cANS✔✔(1) ccommunication c(2
cimprovement c(4) cplanning cand cevaluation cof cpatient coutcomes c(5) clegal cdocumentation c(6) cpr
c(7) creimbursement cand cutilization creview c(8) ceducation cand cresearch
Purpose cof cdocumentation: c- cCORRECT cANS✔✔Clear, ccomplete, cconcise, ccomprehensive, can
cclient chealth crecord.
Documentation: cCommunication c- cCORRECT cANS✔✔Members cof cthe cinterdisciplinary cteam cu
ccommunicate cabout cthe cpatients cstatus cand ccare.
Documentation: cContinuity cof cCare c- cCORRECT cANS✔✔Continuation cof ccare csmoothly cfrom co
cthat cthe cpatient creceives cthe cmost cbenefit cand cno cinterruption cin ccare.
Documentation: cQuality cImprovement c- cCORRECT cANS✔✔review cof cmanual ccharts caudits can
cstrategies cto cimprove ccare, cdecrease clength cof cstay, ccontrol ccost, cand cidentify cknowledge can
caddressed cthrough cin cservices cand ccontinued ceducation.
manual cchart caudits c- cCORRECT cANS✔✔directed creviews cof cclient cmedical crecords
Documentation: cPlanning cand cEvaluation cof cPatient cOutcomes c- cCORRECT cANS✔✔Enables cp
chealth ccare cprofessionals cto cplan cand cevaluate ctreatment cand cmonitor chealth cstatus cover ctim
Documentation: cProfessional cStandards cof cCare c(ANA) c- cScope cand cStandards cof cPractice c- c
cdocuments crelevant cdata c(2) cdocuments cdiagnoses c(3) cdocuments cexpected coutcome c(4) cdoc
cdocuments cimplementation c(6) cdocuments cthe ccoordination cof cthe ccare c(7) cdocuments cthe cre
ccommunicates ceffectively c(9) ccooperates cin ccreating ca cdocumented cplan
Documents crelevant cdata cin ca cretrievable cformat c- cCORRECT cANS✔✔Standard c1, cAssessme
, Documentation: cReimbursement cand cUtilization cReview c- cCORRECT cANS✔✔Insurance ccompa
cparty cpayers, cbudget cmanagers, cand corganization cbilling cstaff cuse cclient chealth crecords cto cde
utilization creview c- cCORRECT cANS✔✔Review cof chealth crecords cto cdetermine cwhether cthe cme
cinterventions cwere cnecessary cand cappropriate.
Documentation: cEducation cand cResearch c- cCORRECT cANS✔✔health crecords cused cto ccollect
cis cused cto ctowards cbetter cunderstanding cthe ccauses cand cprogression cof cdiseases, ctreatment
cvaried cpopulations cand cdiseases
Importance cof cstandard cNursing cLanguage c- cCORRECT cANS✔✔allowed ca cstandard cof ceviden
cdelivery cto cbe cestablished.
NIC c- cCORRECT cANS✔✔Nursing cIntervention cClassification
NOC c- cCORRECT cANS✔✔Nursing cOutcomes cClassification
Source- cOriented cRecord cSystem c- cCORRECT cANS✔✔Members cof ceach cdiscipline crecord cth
clabeled cdiscipline crecord ctheir cfindings cin ca cseparately clabeled csection cof cthe cchart.
What cis cincluded cin cSource-Orientated cRecords: c- cCORRECT cANS✔✔(1)Admission cdata c(2)A
cand cPhysical c(4)Providers corders c(5)Progress cnotes c(6) cDiagnostic cstudies c(7)Laboratory cdata
cGraphic cdata c(10) cRehabilitation cand cTherapy cnotes c(11) cDischarge cplanning
Admission cData c- cCORRECT cANS✔✔-demographic cinformation
-insurance cdata
-contact cinformation
Advanced cDirective c- cCORRECT cANS✔✔Information con cclients cwishes cfor cthe cextent cof ccare
cshould cbe cgiven cin cthe cevent cof ca clife cthreatening cevent
History cand cPhysical c- cCORRECT cANS✔✔-detailed csummary cof cthe ccurrent chealth cproblems
-past cmedical, csurgical cand csocial chistory
-medications ctaken
-allergies
-review cof csystems cand cphysical cexam cdata
Providers cNotes c- cCORRECT cANS✔✔Orders cfor:
-medications
-treatments
-activities
Progress cNotes c- cCORRECT cANS✔✔Chronological ccharting cby chealth ccare cteam cmembers cin
-patient cexams
-problems cidentification
-patient cresponse cto ctherapy
Diagnostic cStudies c- cCORRECT cANS✔✔Reports cdetailing cthe cfindings cof ctest cthat chave cbeen
- cx-rays
-ultrasounds
-pulmonary cfunction ctesting
Laboratory cData c- cCORRECT cANS✔✔Reuslts cfrom cdiagnostic ctest csuch cas ccomplete cblood cc
Answers
How cdo chealthcare cproviders cuse cdocumentation? c- cCORRECT cANS✔✔(1) ccommunication c(2
cimprovement c(4) cplanning cand cevaluation cof cpatient coutcomes c(5) clegal cdocumentation c(6) cpr
c(7) creimbursement cand cutilization creview c(8) ceducation cand cresearch
Purpose cof cdocumentation: c- cCORRECT cANS✔✔Clear, ccomplete, cconcise, ccomprehensive, can
cclient chealth crecord.
Documentation: cCommunication c- cCORRECT cANS✔✔Members cof cthe cinterdisciplinary cteam cu
ccommunicate cabout cthe cpatients cstatus cand ccare.
Documentation: cContinuity cof cCare c- cCORRECT cANS✔✔Continuation cof ccare csmoothly cfrom co
cthat cthe cpatient creceives cthe cmost cbenefit cand cno cinterruption cin ccare.
Documentation: cQuality cImprovement c- cCORRECT cANS✔✔review cof cmanual ccharts caudits can
cstrategies cto cimprove ccare, cdecrease clength cof cstay, ccontrol ccost, cand cidentify cknowledge can
caddressed cthrough cin cservices cand ccontinued ceducation.
manual cchart caudits c- cCORRECT cANS✔✔directed creviews cof cclient cmedical crecords
Documentation: cPlanning cand cEvaluation cof cPatient cOutcomes c- cCORRECT cANS✔✔Enables cp
chealth ccare cprofessionals cto cplan cand cevaluate ctreatment cand cmonitor chealth cstatus cover ctim
Documentation: cProfessional cStandards cof cCare c(ANA) c- cScope cand cStandards cof cPractice c- c
cdocuments crelevant cdata c(2) cdocuments cdiagnoses c(3) cdocuments cexpected coutcome c(4) cdoc
cdocuments cimplementation c(6) cdocuments cthe ccoordination cof cthe ccare c(7) cdocuments cthe cre
ccommunicates ceffectively c(9) ccooperates cin ccreating ca cdocumented cplan
Documents crelevant cdata cin ca cretrievable cformat c- cCORRECT cANS✔✔Standard c1, cAssessme
, Documentation: cReimbursement cand cUtilization cReview c- cCORRECT cANS✔✔Insurance ccompa
cparty cpayers, cbudget cmanagers, cand corganization cbilling cstaff cuse cclient chealth crecords cto cde
utilization creview c- cCORRECT cANS✔✔Review cof chealth crecords cto cdetermine cwhether cthe cme
cinterventions cwere cnecessary cand cappropriate.
Documentation: cEducation cand cResearch c- cCORRECT cANS✔✔health crecords cused cto ccollect
cis cused cto ctowards cbetter cunderstanding cthe ccauses cand cprogression cof cdiseases, ctreatment
cvaried cpopulations cand cdiseases
Importance cof cstandard cNursing cLanguage c- cCORRECT cANS✔✔allowed ca cstandard cof ceviden
cdelivery cto cbe cestablished.
NIC c- cCORRECT cANS✔✔Nursing cIntervention cClassification
NOC c- cCORRECT cANS✔✔Nursing cOutcomes cClassification
Source- cOriented cRecord cSystem c- cCORRECT cANS✔✔Members cof ceach cdiscipline crecord cth
clabeled cdiscipline crecord ctheir cfindings cin ca cseparately clabeled csection cof cthe cchart.
What cis cincluded cin cSource-Orientated cRecords: c- cCORRECT cANS✔✔(1)Admission cdata c(2)A
cand cPhysical c(4)Providers corders c(5)Progress cnotes c(6) cDiagnostic cstudies c(7)Laboratory cdata
cGraphic cdata c(10) cRehabilitation cand cTherapy cnotes c(11) cDischarge cplanning
Admission cData c- cCORRECT cANS✔✔-demographic cinformation
-insurance cdata
-contact cinformation
Advanced cDirective c- cCORRECT cANS✔✔Information con cclients cwishes cfor cthe cextent cof ccare
cshould cbe cgiven cin cthe cevent cof ca clife cthreatening cevent
History cand cPhysical c- cCORRECT cANS✔✔-detailed csummary cof cthe ccurrent chealth cproblems
-past cmedical, csurgical cand csocial chistory
-medications ctaken
-allergies
-review cof csystems cand cphysical cexam cdata
Providers cNotes c- cCORRECT cANS✔✔Orders cfor:
-medications
-treatments
-activities
Progress cNotes c- cCORRECT cANS✔✔Chronological ccharting cby chealth ccare cteam cmembers cin
-patient cexams
-problems cidentification
-patient cresponse cto ctherapy
Diagnostic cStudies c- cCORRECT cANS✔✔Reports cdetailing cthe cfindings cof ctest cthat chave cbeen
- cx-rays
-ultrasounds
-pulmonary cfunction ctesting
Laboratory cData c- cCORRECT cANS✔✔Reuslts cfrom cdiagnostic ctest csuch cas ccomplete cblood cc
