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Documentation Ch 3 Test review
Questions and Correct Answers/ Latest
Update / Already Graded
In managed care, documentation is especially significant because:
Ans: B) institutions are reimbursed only for patient care that is
documented
When the nurse charts only additional treatments done, changes in
patient condition, and new concerns, the system of documentation is:
Ans: C) CBE.
When events are not consistent with facility or national standards of
expected care, the form that explains the lapse is the:
Ans: C) incident report.
When staff from all disciplines develop integrated care plans for a
projected length of stay for patients of a specific case type, it is known
as a:
Ans: D) critical pathway.
Home health care documentation is unique because:
All rights reserved © 2025/ 2026 |
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Ans: C) different health care providers need access.
Standards for long-term care documentation are regulated by:
Ans: A) OBRA.
Adherence to the concept of confidentiality for the patient's medical
record requires that the nurse:
Ans: D) have a clinical reason for reading the record.
Documentation is necessary for the evaluation of patient care and is an
integral part of the nursing process phase of:
Ans: C) implementation.
When focus charting, what does the nurse use as a basis for
documentation?
Ans: C) Nursing diagnoses
The purpose of QA (quality assurance) is to:
Ans: B) evaluate care results against accepted standards
All rights reserved © 2025/ 2026 |
Documentation Ch 3 Test review
Questions and Correct Answers/ Latest
Update / Already Graded
In managed care, documentation is especially significant because:
Ans: B) institutions are reimbursed only for patient care that is
documented
When the nurse charts only additional treatments done, changes in
patient condition, and new concerns, the system of documentation is:
Ans: C) CBE.
When events are not consistent with facility or national standards of
expected care, the form that explains the lapse is the:
Ans: C) incident report.
When staff from all disciplines develop integrated care plans for a
projected length of stay for patients of a specific case type, it is known
as a:
Ans: D) critical pathway.
Home health care documentation is unique because:
All rights reserved © 2025/ 2026 |
, Page |2
Ans: C) different health care providers need access.
Standards for long-term care documentation are regulated by:
Ans: A) OBRA.
Adherence to the concept of confidentiality for the patient's medical
record requires that the nurse:
Ans: D) have a clinical reason for reading the record.
Documentation is necessary for the evaluation of patient care and is an
integral part of the nursing process phase of:
Ans: C) implementation.
When focus charting, what does the nurse use as a basis for
documentation?
Ans: C) Nursing diagnoses
The purpose of QA (quality assurance) is to:
Ans: B) evaluate care results against accepted standards
All rights reserved © 2025/ 2026 |
