EXAM: Documentation and Informatics EAQ:
Questions with Complete Solutions
enter only objective and subjective information CORRECT ANS-A manager who is
reviewing the nurses' notes in a patient's medical record finds the following entry, "The
patient is difficult to care for and refuses suggestions for improving appetite." Which
directions does the manager give to the staff nurse who entered the note?
oral communication and written reports CORRECT ANS-Communication among the
members of a healthcare team is essential to providing quality care to patients. Which are the
modes for exchanging information among the members of the healthcare team?
hand off report CORRECT ANS-At the end of a shift, the nurse documents a patient's
condition, anticipated condition, medications, and nursing interventions fulfilled so that the
next nurse can follow the appropriate treatment plan and care for the patient. What is this
kind of report?
the patients incision site looks clean without any purulent drainage or erythema CORRECT
ANS-The nurse assesses a patient on day 3 after surgery and charts a progress note in the
SOAP (subjective data, objective data, assessment, and plan) format. Which is considered an
objective datum?
, EXAM: Documentation and Informatics EAQ:
Questions with Complete Solutions
you need to use words that the patients understand when writing a teaching sheet
CORRECT ANS-You are helping to design a new teaching sheet that will go home with
patients who are discharged home from your unit. Which option do you need to remember
when designing the teaching sheet?
HIPPA CORRECT ANS-The nurse faxes a patient's medical record to an unknown number.
Which law is the nurse violating?
transfer reports CORRECT ANS-A patient was shifted from the intensive care unit to the
cardiac unit. What kinds of reports are used to communicate between the two units?
integrates all pertinent patient information into one record, performs checks to support
regulatory requirements, provides the means to compare ongoing clinical data with baseline
information CORRECT ANS-The nurse is giving information to a group of caregivers about
electronic health records (EHRs). What information about the EHR should the nurse offer
them?
Questions with Complete Solutions
enter only objective and subjective information CORRECT ANS-A manager who is
reviewing the nurses' notes in a patient's medical record finds the following entry, "The
patient is difficult to care for and refuses suggestions for improving appetite." Which
directions does the manager give to the staff nurse who entered the note?
oral communication and written reports CORRECT ANS-Communication among the
members of a healthcare team is essential to providing quality care to patients. Which are the
modes for exchanging information among the members of the healthcare team?
hand off report CORRECT ANS-At the end of a shift, the nurse documents a patient's
condition, anticipated condition, medications, and nursing interventions fulfilled so that the
next nurse can follow the appropriate treatment plan and care for the patient. What is this
kind of report?
the patients incision site looks clean without any purulent drainage or erythema CORRECT
ANS-The nurse assesses a patient on day 3 after surgery and charts a progress note in the
SOAP (subjective data, objective data, assessment, and plan) format. Which is considered an
objective datum?
, EXAM: Documentation and Informatics EAQ:
Questions with Complete Solutions
you need to use words that the patients understand when writing a teaching sheet
CORRECT ANS-You are helping to design a new teaching sheet that will go home with
patients who are discharged home from your unit. Which option do you need to remember
when designing the teaching sheet?
HIPPA CORRECT ANS-The nurse faxes a patient's medical record to an unknown number.
Which law is the nurse violating?
transfer reports CORRECT ANS-A patient was shifted from the intensive care unit to the
cardiac unit. What kinds of reports are used to communicate between the two units?
integrates all pertinent patient information into one record, performs checks to support
regulatory requirements, provides the means to compare ongoing clinical data with baseline
information CORRECT ANS-The nurse is giving information to a group of caregivers about
electronic health records (EHRs). What information about the EHR should the nurse offer
them?
