Fundamentals of Nursing: Documentation Test Questions and
Answers Rated A
Documentation: - - Produces a written
account of pertinent patient data, nursing clinical According to HIPAA (Health Insurance Portability
decision and interventions, and patient and Accountability Act), to eliminate barriers that
responses in a health care record. could delay care, providers are: - - a.
Providers are required to notify patients of their
privacy policy and make a reasonable effort to
Communication - - Means by which patient get written acknowledgement of this notification.
needs and progress, individual therapies, patient
education, and discharge planning are conveyed b. HIPAA requires that disclosure or requests
to others in the health care team. regarding health information are limited to the
minimum necessary.
Legal document - - Describes exactly what
happens to the patient and must follow agency The standards of documentation by the Joint
standards. Commission require: - - The standards of
documentation by The Joint Commission require
documentation within the context of the nursing
Diagnostic-related groups (DRGs) - - process, as well as evidence of patient and family
Classification system based on patients' medical teaching and discharge planning.
diagnoses that support reimbursement.
Five important guidelines must be followed to
ensure quality documentation and reporting.
Education - - Learning the nature of an
illness and the individual patient's responses. Explain: Factual - - A factual record
contains descriptive, objective information about
what a nurse sees, hears, feels, and smells.
Research - - Gathering of statistical data of
clinical disorders, complications, therapies,
Five important guidelines must be followed to
recovery, and deaths.
ensure quality documentation and reporting.
Explain: Accurate - - An accurate record
uses exact measurements, contains concise
Auditing - - Objective, ongoing reviews to
data, contains only approved abbreviations, uses
determine the degree to which quality
correct spelling, and identifies the date and
improvement standards are met.
caregiver.
The purpose of the electronic health record is: -
Five important guidelines must be followed to
- a. A positive impact on the quality of ensure quality documentation and reporting.
patient care through interdisciplinary
Explain: Complete - - A complete record
collaboration with improved data availability.
contains all appropriate and essential
information.
b. Improve patient safety through the use of
clinical decision support.
1/4
Answers Rated A
Documentation: - - Produces a written
account of pertinent patient data, nursing clinical According to HIPAA (Health Insurance Portability
decision and interventions, and patient and Accountability Act), to eliminate barriers that
responses in a health care record. could delay care, providers are: - - a.
Providers are required to notify patients of their
privacy policy and make a reasonable effort to
Communication - - Means by which patient get written acknowledgement of this notification.
needs and progress, individual therapies, patient
education, and discharge planning are conveyed b. HIPAA requires that disclosure or requests
to others in the health care team. regarding health information are limited to the
minimum necessary.
Legal document - - Describes exactly what
happens to the patient and must follow agency The standards of documentation by the Joint
standards. Commission require: - - The standards of
documentation by The Joint Commission require
documentation within the context of the nursing
Diagnostic-related groups (DRGs) - - process, as well as evidence of patient and family
Classification system based on patients' medical teaching and discharge planning.
diagnoses that support reimbursement.
Five important guidelines must be followed to
ensure quality documentation and reporting.
Education - - Learning the nature of an
illness and the individual patient's responses. Explain: Factual - - A factual record
contains descriptive, objective information about
what a nurse sees, hears, feels, and smells.
Research - - Gathering of statistical data of
clinical disorders, complications, therapies,
Five important guidelines must be followed to
recovery, and deaths.
ensure quality documentation and reporting.
Explain: Accurate - - An accurate record
uses exact measurements, contains concise
Auditing - - Objective, ongoing reviews to
data, contains only approved abbreviations, uses
determine the degree to which quality
correct spelling, and identifies the date and
improvement standards are met.
caregiver.
The purpose of the electronic health record is: -
Five important guidelines must be followed to
- a. A positive impact on the quality of ensure quality documentation and reporting.
patient care through interdisciplinary
Explain: Complete - - A complete record
collaboration with improved data availability.
contains all appropriate and essential
information.
b. Improve patient safety through the use of
clinical decision support.
1/4
