Chapter 3: Documentation 2025 Questions and Answers
1. What does documentation of type of care, time of care, and signature of the person prove?
a. The person who signed the documentation did all the work noted.
b. No litigation can be brought against the person who signed.
c. Interventions were implemented to meet the patient's needs.
d. The patient's response to the intervention was positive. - ansANS: C
Documenting type of care, time of care, and signature of the person results in recording the interventions that
are implemented to meet the patient's needs. Many charting entries include doctor's visits, presence of family,
or interventions by other departments. Patient response to some interventions is not always positive.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38 OBJ: 1 TOP: Documentation
KEY: Nursing Process Step: Implementation
2. Why is documentation especially significant in managed care?
a. The hospital needs to show that employees care for patients.
b. Institutions are reimbursed only for patient care that is documented.
c. Patients might bring lawsuits if care was not given.
d. Documents may become part of a lawsuit. - ansANS: B
Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment
system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical
procedure, and other information with hundreds of different categories to predict the use of hospital
resources, including length of stay, resulting in a fixed payment amount.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 40
OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A
3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is
this system of documentation?
a. SOAP
, b. Block
c. CBE
d. Focus - ansANS: C
Charting additional treatments done, changes in a patient's condition, and new concerns during the shift is
charting by exception (CBE).
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 46
OBJ: 1 | 5 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
4. What form explains the lapse when events are not consistent with facility or national standards of expected
care?
a. Subjective data
b. Focus chart
c. Incident report
d. Nursing assessment - ansANS: C
An incident report is completed when patient care was not consistent with facility or national standards. The
form explains the event, time, extent of injury, and who was notified.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 47
OBJ: 1 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of
a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway. - ansANS: D
Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay
for patients of a specific case type.
1. What does documentation of type of care, time of care, and signature of the person prove?
a. The person who signed the documentation did all the work noted.
b. No litigation can be brought against the person who signed.
c. Interventions were implemented to meet the patient's needs.
d. The patient's response to the intervention was positive. - ansANS: C
Documenting type of care, time of care, and signature of the person results in recording the interventions that
are implemented to meet the patient's needs. Many charting entries include doctor's visits, presence of family,
or interventions by other departments. Patient response to some interventions is not always positive.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 38 OBJ: 1 TOP: Documentation
KEY: Nursing Process Step: Implementation
2. Why is documentation especially significant in managed care?
a. The hospital needs to show that employees care for patients.
b. Institutions are reimbursed only for patient care that is documented.
c. Patients might bring lawsuits if care was not given.
d. Documents may become part of a lawsuit. - ansANS: B
Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment
system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical
procedure, and other information with hundreds of different categories to predict the use of hospital
resources, including length of stay, resulting in a fixed payment amount.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 40
OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A
3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is
this system of documentation?
a. SOAP
, b. Block
c. CBE
d. Focus - ansANS: C
Charting additional treatments done, changes in a patient's condition, and new concerns during the shift is
charting by exception (CBE).
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 46
OBJ: 1 | 5 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
4. What form explains the lapse when events are not consistent with facility or national standards of expected
care?
a. Subjective data
b. Focus chart
c. Incident report
d. Nursing assessment - ansANS: C
An incident report is completed when patient care was not consistent with facility or national standards. The
form explains the event, time, extent of injury, and who was notified.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 47
OBJ: 1 | 7 TOP: Documentation KEY: Nursing Process Step: N/A
5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of
a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway. - ansANS: D
Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay
for patients of a specific case type.
