MGCCC Nursing Unit 3 Exam Questions
with correct Answers
documentation - correct answersprovides a written record that can communicate
observations and data to the healthcare team
types of documented reports - correct answers- change of shift reports
- telephone reports
- telephone orders
- transfer reports
change of shift reports - correct answers(walk around)
data should be objective, current, and concise; avoid unprofessional comments
telephone reports/ orders - correct answersused during significant events or changes; used
only when absolutely necessary, at night or in an emergency
purpose of a client record - correct answers- communication (between providers)
- legal documentation (used in court)
- reimbursement (verifies financial charges)
elements of a patients record - correct answers- patient identification
- record of nursing care, treatment, and evaluation
- therapeutic orders
, guidelines for quality/effective documentation (FACCO) - correct answers- factual
- accurate
- complete
- current
- organized
SOAP - correct answers- subjective
- objective
- assessment
- plan
SOAPIE - correct answers- subjective
- objective
- assessment
- plan
- intervention
- evaluation
PIE - correct answers- problem
- intervention
- evaluation
focus charting (DAR) - correct answers- data
- action
- response
with correct Answers
documentation - correct answersprovides a written record that can communicate
observations and data to the healthcare team
types of documented reports - correct answers- change of shift reports
- telephone reports
- telephone orders
- transfer reports
change of shift reports - correct answers(walk around)
data should be objective, current, and concise; avoid unprofessional comments
telephone reports/ orders - correct answersused during significant events or changes; used
only when absolutely necessary, at night or in an emergency
purpose of a client record - correct answers- communication (between providers)
- legal documentation (used in court)
- reimbursement (verifies financial charges)
elements of a patients record - correct answers- patient identification
- record of nursing care, treatment, and evaluation
- therapeutic orders
, guidelines for quality/effective documentation (FACCO) - correct answers- factual
- accurate
- complete
- current
- organized
SOAP - correct answers- subjective
- objective
- assessment
- plan
SOAPIE - correct answers- subjective
- objective
- assessment
- plan
- intervention
- evaluation
PIE - correct answers- problem
- intervention
- evaluation
focus charting (DAR) - correct answers- data
- action
- response
