ATI Fundamentals Documentation
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the
following characteristics should the charge nurse plan to include? (Select all that apply.)
A. Reduces medical errors
B. Improves listening skills among interdisciplinary team members
C. Less convenient than paper-based charting
D. Makes client medical history more easily available
E. Increases accuracy of coding procedures - ANS -A. Reduces medical errors is correct. The charge nurse should inform
the staff that electronic documentation systems can help reduce medical errors.
D. Makes client medical history more easily available is correct. The charge nurse should include that electronic records
help to make client information readily available to health care professionals.
E. Increases accuracy of coding procedures is correct. The charge nurse should inform the staff that electronic records
can lead to more reliable coding and billing for client conditions.
\A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart
entries should the nurse include as an example of objective data?
A. The client states, "I've had abdominal pain for the past 3 days."
B. The client reports consuming about 1,500 mL of water per day.
C. Rebound tenderness noted in RLQ of the abdomen.
D. Recommend client referral to a registered dietitian. - ANS -C. Rebound tenderness noted in RLQ of the abdomen.
Objective data is information the nurse gathers when collecting data about the client, such as through physical
assessment or diagnostic testing.
, \A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document
variations from an expected set of findings when performing a physical assessment. The nurse should identify this system
as which of the following documentation methods?
A. Charting by exception
B. Subjective, objective, assessment, plan format
C. Problem, intervention, evaluation model
D. Data, action, response charting - ANS -A. Charting by exception
With charting by exception (CBE), health care professionals only chart unexpected findings. This can be done on a
flowsheet or through narrative notes.
\A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of
the following abbreviations indicates the medication can be taken as needed?
A. PRN
B. NPO
C. AC
D. Ad lib - ANS -A. PRN
PRN is the abbreviation for "as needed." It is included in the list of commonly used medical abbreviations. The nurse
should ensure the client understands other instructions for PRN administration, such as the frequency or the reason the
medication should be taken.
\A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements
from a staff member indicates an understanding of a CPOE system?
A. "CPOE systems are associated with a slightly higher error rate."
B. "CPOE use does not include medication prescriptions."
C. "CPOE systems can increase the speed of care delivery."
D. "CPOE use is mandated by HIPAA under the Privacy Rule." - ANS -C. "CPOE systems can increase the speed of care
delivery."
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the
following characteristics should the charge nurse plan to include? (Select all that apply.)
A. Reduces medical errors
B. Improves listening skills among interdisciplinary team members
C. Less convenient than paper-based charting
D. Makes client medical history more easily available
E. Increases accuracy of coding procedures - ANS -A. Reduces medical errors is correct. The charge nurse should inform
the staff that electronic documentation systems can help reduce medical errors.
D. Makes client medical history more easily available is correct. The charge nurse should include that electronic records
help to make client information readily available to health care professionals.
E. Increases accuracy of coding procedures is correct. The charge nurse should inform the staff that electronic records
can lead to more reliable coding and billing for client conditions.
\A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart
entries should the nurse include as an example of objective data?
A. The client states, "I've had abdominal pain for the past 3 days."
B. The client reports consuming about 1,500 mL of water per day.
C. Rebound tenderness noted in RLQ of the abdomen.
D. Recommend client referral to a registered dietitian. - ANS -C. Rebound tenderness noted in RLQ of the abdomen.
Objective data is information the nurse gathers when collecting data about the client, such as through physical
assessment or diagnostic testing.
, \A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document
variations from an expected set of findings when performing a physical assessment. The nurse should identify this system
as which of the following documentation methods?
A. Charting by exception
B. Subjective, objective, assessment, plan format
C. Problem, intervention, evaluation model
D. Data, action, response charting - ANS -A. Charting by exception
With charting by exception (CBE), health care professionals only chart unexpected findings. This can be done on a
flowsheet or through narrative notes.
\A nurse in a clinic is reviewing a client's prescriptions prior to discharge. The nurse should instruct the client that which of
the following abbreviations indicates the medication can be taken as needed?
A. PRN
B. NPO
C. AC
D. Ad lib - ANS -A. PRN
PRN is the abbreviation for "as needed." It is included in the list of commonly used medical abbreviations. The nurse
should ensure the client understands other instructions for PRN administration, such as the frequency or the reason the
medication should be taken.
\A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements
from a staff member indicates an understanding of a CPOE system?
A. "CPOE systems are associated with a slightly higher error rate."
B. "CPOE use does not include medication prescriptions."
C. "CPOE systems can increase the speed of care delivery."
D. "CPOE use is mandated by HIPAA under the Privacy Rule." - ANS -C. "CPOE systems can increase the speed of care
delivery."
