NUR 152 Exam 4 Documentation Questions With Complete
Solutions
Accurate documentations contains what? Correct Answers -
Concise, clear, easy to understand
Correct spelling and approved abbreviations only
-Be objective, specific, factual
Quote pt/ fam. or document observations
- Must sign at end for accountability
EBP and agency P&P should ALWAYS be based on what, and
NEVER based on what? Correct Answers -Always based on
latest research
-Never based on "the way it's always been done"
EMR acronym stands for? Correct Answers Electronic Medical
Record
Falsification of documentation is what? What are the
consequences? Correct Answers -It is fraud
-If fraud is committed, stiff penalties will ensue and loss of
medicare provider status
Forms of communicating in a healthcare environment? Correct
Answers -Oral
-Written
-Electronic
-Audio taped
-Telephone
-Fax or email
, Good factual documentation contains what? Correct Answers
DESCRIPTIVE (no vague generalities) , objective info about
the pt.
Says what the RN sees, hears, feels or smells
Documents pts. words in quotes
Document measurable data when possible
Avoids opinions or judgements
HCP acronym stands for? Correct Answers Health Care
Provider
HCR acronym means? Correct Answers Health Care Record
How can you as a RN ensure that EBP and P&P's are always
based on current research? Correct Answers Read journals,
attend seminars/ workshops, network, join organizations
How do nurses and physician communication styles differ?
Correct Answers - Nurses have more of a narrative descriptive
explanation
- Physicians would rather just have facts
How do you know if research/ EBP is accurate or valid? Correct
Answers You can check Library/ Scholarly web based data
bases to check accuracy and currency
How do you verify accuracy of a verbal order given by MD?
Correct Answers Write it down in medical record on physician
order form and repeat it back
MD must sign it withing specific time frame
Solutions
Accurate documentations contains what? Correct Answers -
Concise, clear, easy to understand
Correct spelling and approved abbreviations only
-Be objective, specific, factual
Quote pt/ fam. or document observations
- Must sign at end for accountability
EBP and agency P&P should ALWAYS be based on what, and
NEVER based on what? Correct Answers -Always based on
latest research
-Never based on "the way it's always been done"
EMR acronym stands for? Correct Answers Electronic Medical
Record
Falsification of documentation is what? What are the
consequences? Correct Answers -It is fraud
-If fraud is committed, stiff penalties will ensue and loss of
medicare provider status
Forms of communicating in a healthcare environment? Correct
Answers -Oral
-Written
-Electronic
-Audio taped
-Telephone
-Fax or email
, Good factual documentation contains what? Correct Answers
DESCRIPTIVE (no vague generalities) , objective info about
the pt.
Says what the RN sees, hears, feels or smells
Documents pts. words in quotes
Document measurable data when possible
Avoids opinions or judgements
HCP acronym stands for? Correct Answers Health Care
Provider
HCR acronym means? Correct Answers Health Care Record
How can you as a RN ensure that EBP and P&P's are always
based on current research? Correct Answers Read journals,
attend seminars/ workshops, network, join organizations
How do nurses and physician communication styles differ?
Correct Answers - Nurses have more of a narrative descriptive
explanation
- Physicians would rather just have facts
How do you know if research/ EBP is accurate or valid? Correct
Answers You can check Library/ Scholarly web based data
bases to check accuracy and currency
How do you verify accuracy of a verbal order given by MD?
Correct Answers Write it down in medical record on physician
order form and repeat it back
MD must sign it withing specific time frame
