Nurs 371 Exam Questions and Answers 100%
Pass
Documentation is - ✔✔The written or electronic legal record of all pertinent interactions with the
patient assessing diagnosing planning implementing and evaluating
Characteristic of effective documentation - ✔✔Consistent with professional and agency standerds,
complete , accurate, concise, factual, organized and timely, legally prudent, confidential
What is confidential? - ✔✔All information about patients written on paper spoken aloud saved on
commuter (Name, address, phone, fax social security, reason the person is sick, assessments and
treatments patient receives, information about past health conditions)
A nurse who fails to log off a commuter after documenting patient care has breached patient
confidentiallity true or false - ✔✔True
A patient has the right to obtain review and revise the patient information in his or her health record
True or false - ✔✔False
Records included: - ✔✔client identification and demogrphic data, informed consent for treatment and
procedures, admission nursing history, nursing diagnoses or problems, nursing or multidiscriplinary care
plan includes respiratory disease, records of nursing care treatment and evaluation, medical history,
medical diagnosis, therapy orders, medical and health discipline progress notes, reports of physical
examinations, reports of diagnostic studies, summary of operative procedures, discharge plan and
summary
Page 1/35
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,Purpose of patient records - ✔✔Communication with other healthcare professionals, records of
diagnostic and therapeutic orders, care plannning, quality process and performance improvement,
research, decision analysis, education, credentialing regulation and legislation, legal and historical
documentation, reimbursement, facilitate patient care, serve as a financial and legal record, help in
clinical research, support decision analysis
Guidelines for receiving verbal orders in an emergency - ✔✔record the orders in patients medical
records, read back the order to verify accuracy, date and not the time orders were issued in emergency,
record VO, the name of the physician or nurse practitioner followed by nurses name and title, the
registered professional nurse nurse must see that the orders are transcribed according to procedure
Terminology used: - ✔✔Medical terminology used to facilitate communication, breakdown medical
terminology into the three parts prefix root suffix
Terminology Abbreviation notes - ✔✔Keep to standard abbreviation different areas or specialties vary,
know approved abbreviation for specific agency
Documentation Essentials Legal document: What you need: - ✔✔Black ink, contain facts and be
accurate, legible, brief/concise, exact time (may be military time), logical by time and content,
Errors/Omissions, no blank spaces, signature
Good assessors are usuallly good charters why? - ✔✔Assessing from head to toe paining a good picture
should chart what you did and saw
Charting: - ✔✔Takes time and practice, practice, proactive, you will always be perfecting the skill
When to chart? - ✔✔Admission, assuming care, transferring a patient, discharging a patient
Page 2/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
,Types of entries: - ✔✔Newly admitted patient, opening notes for shift, interval notes(when something
has changed), anything abnormal, any change, test, lab, doctor visit, dietitian show orders carried out,
transfer discharge
Documentation essentials: - ✔✔Patient teaching, entries should be objective avoid good, bad, seems
like, do symptom analysis on complaints/pain, Entries must reflect patient needs if you find something
wrong you must chart what you did and how your patient responded, dressing should not location
attachments drainage not skin condition if removed, tubes state type placement infusion site condition
drainage suction, Mar available for routine meds PRN are entered in narrative notes with assessment
intervention and response note meds not given (when patient complains of pain state nurse notified ,
Psychosocial-LOC and safety, ADL-flow sheet/transfer needs, Jewelry- describe (gold-yellow) where sent
and who recieved, spiritual care- not expression of grief/anger symbols/rituals, sins of distress sources of
hope, safety:side rails ambulation call light restraints teaching about safety incident form is fall,
elderly:ADL mobility safety mental status affective behavior
Methods of documentation: source oriented - ✔✔Separate division for each discipline, may be narrative
Methods of documentation problem oriented - ✔✔data base, problem list, plans, progress
Documentation formats-problem oriented: - ✔✔SOAP: subjective data, objective data, assessment, plan
APIE: assessment, problems, interventions, evaluations
Focus:Data, action, response
charting by exception
case management model
collaborative pathways
Page 3/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
, occurrence charting
computerized records
Documentation formats: - ✔✔24 hour assessment -note abnormal findings in narrative
kardex plan of care/needs list
pathways
progress notes
flow sheets (graphics, I&O, MAR)
-Follow trends
-organized
-consistent
-needs date/time./initials
fix this charting: c/o burning pain on urination, fowl, smelling, yellow, cloudy urine...........J.Doe, RN -
✔✔C/o burning pain on urination, foul, smelling, cloudy yellow urine...........J.Doe, RN
fix this charting: stool well-formed, polls then larger pieces, medium brown in color....J.Jones, RN -
✔✔stool well-formed, large formed medium brown stool....J.Jones, RN
fix this charting: Denies pain, o2 on at 2L/min per nasal cannula. IV of D5W patent at 21 gets/min.c
300cc TBA, awake, alert, urine clear yellow, lungs clear, oriented x3........ K.Smith, RN - ✔✔Denies pain.
awake,alert, oriented x3..lungs clear, o2 on at 2L/min per nasal cannula. IV of D5W patent at 21
gets/min.c 300 cc TBA, the sit is without redness or swelling, urine clear yellow...........K.Smilth, RN
Page 4/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
Pass
Documentation is - ✔✔The written or electronic legal record of all pertinent interactions with the
patient assessing diagnosing planning implementing and evaluating
Characteristic of effective documentation - ✔✔Consistent with professional and agency standerds,
complete , accurate, concise, factual, organized and timely, legally prudent, confidential
What is confidential? - ✔✔All information about patients written on paper spoken aloud saved on
commuter (Name, address, phone, fax social security, reason the person is sick, assessments and
treatments patient receives, information about past health conditions)
A nurse who fails to log off a commuter after documenting patient care has breached patient
confidentiallity true or false - ✔✔True
A patient has the right to obtain review and revise the patient information in his or her health record
True or false - ✔✔False
Records included: - ✔✔client identification and demogrphic data, informed consent for treatment and
procedures, admission nursing history, nursing diagnoses or problems, nursing or multidiscriplinary care
plan includes respiratory disease, records of nursing care treatment and evaluation, medical history,
medical diagnosis, therapy orders, medical and health discipline progress notes, reports of physical
examinations, reports of diagnostic studies, summary of operative procedures, discharge plan and
summary
Page 1/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
,Purpose of patient records - ✔✔Communication with other healthcare professionals, records of
diagnostic and therapeutic orders, care plannning, quality process and performance improvement,
research, decision analysis, education, credentialing regulation and legislation, legal and historical
documentation, reimbursement, facilitate patient care, serve as a financial and legal record, help in
clinical research, support decision analysis
Guidelines for receiving verbal orders in an emergency - ✔✔record the orders in patients medical
records, read back the order to verify accuracy, date and not the time orders were issued in emergency,
record VO, the name of the physician or nurse practitioner followed by nurses name and title, the
registered professional nurse nurse must see that the orders are transcribed according to procedure
Terminology used: - ✔✔Medical terminology used to facilitate communication, breakdown medical
terminology into the three parts prefix root suffix
Terminology Abbreviation notes - ✔✔Keep to standard abbreviation different areas or specialties vary,
know approved abbreviation for specific agency
Documentation Essentials Legal document: What you need: - ✔✔Black ink, contain facts and be
accurate, legible, brief/concise, exact time (may be military time), logical by time and content,
Errors/Omissions, no blank spaces, signature
Good assessors are usuallly good charters why? - ✔✔Assessing from head to toe paining a good picture
should chart what you did and saw
Charting: - ✔✔Takes time and practice, practice, proactive, you will always be perfecting the skill
When to chart? - ✔✔Admission, assuming care, transferring a patient, discharging a patient
Page 2/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
,Types of entries: - ✔✔Newly admitted patient, opening notes for shift, interval notes(when something
has changed), anything abnormal, any change, test, lab, doctor visit, dietitian show orders carried out,
transfer discharge
Documentation essentials: - ✔✔Patient teaching, entries should be objective avoid good, bad, seems
like, do symptom analysis on complaints/pain, Entries must reflect patient needs if you find something
wrong you must chart what you did and how your patient responded, dressing should not location
attachments drainage not skin condition if removed, tubes state type placement infusion site condition
drainage suction, Mar available for routine meds PRN are entered in narrative notes with assessment
intervention and response note meds not given (when patient complains of pain state nurse notified ,
Psychosocial-LOC and safety, ADL-flow sheet/transfer needs, Jewelry- describe (gold-yellow) where sent
and who recieved, spiritual care- not expression of grief/anger symbols/rituals, sins of distress sources of
hope, safety:side rails ambulation call light restraints teaching about safety incident form is fall,
elderly:ADL mobility safety mental status affective behavior
Methods of documentation: source oriented - ✔✔Separate division for each discipline, may be narrative
Methods of documentation problem oriented - ✔✔data base, problem list, plans, progress
Documentation formats-problem oriented: - ✔✔SOAP: subjective data, objective data, assessment, plan
APIE: assessment, problems, interventions, evaluations
Focus:Data, action, response
charting by exception
case management model
collaborative pathways
Page 3/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
, occurrence charting
computerized records
Documentation formats: - ✔✔24 hour assessment -note abnormal findings in narrative
kardex plan of care/needs list
pathways
progress notes
flow sheets (graphics, I&O, MAR)
-Follow trends
-organized
-consistent
-needs date/time./initials
fix this charting: c/o burning pain on urination, fowl, smelling, yellow, cloudy urine...........J.Doe, RN -
✔✔C/o burning pain on urination, foul, smelling, cloudy yellow urine...........J.Doe, RN
fix this charting: stool well-formed, polls then larger pieces, medium brown in color....J.Jones, RN -
✔✔stool well-formed, large formed medium brown stool....J.Jones, RN
fix this charting: Denies pain, o2 on at 2L/min per nasal cannula. IV of D5W patent at 21 gets/min.c
300cc TBA, awake, alert, urine clear yellow, lungs clear, oriented x3........ K.Smith, RN - ✔✔Denies pain.
awake,alert, oriented x3..lungs clear, o2 on at 2L/min per nasal cannula. IV of D5W patent at 21
gets/min.c 300 cc TBA, the sit is without redness or swelling, urine clear yellow...........K.Smilth, RN
Page 4/35
Crafted for Academic Insight by ©KatelynWhitman 2025. All rights reserved.
