PN /
108
/ /
Final Exam Questions With Correct Answers
/ // // // // //
intervention //- //verified //answer(s)-✔✔care //provided //to //improve //a //situation
Charting, //recording, //documenting //- //verified //answer(s)-
✔✔the //Process //of //adding //information //to //a //chart //is //called
Documentation //- //verified //answer(s)-
✔✔an /
/integral /
/part /
/of /
/the /
/implementation /
/phase /
/of /
/the /
/nursing /
/process /
/and /
/is /
/necessary /
/for //the //evaluation //of //patient //care //and //for //reimbursement //for //the //cost //of //care //provided
DRG //- //verified //answer(s)-
✔✔diagnostic /
/related /
/group //
a/
,/group /
/that /
/classifies /
/patients /
/by /
/age, /
/diagnosis, /
/surgical /
/procedure, /
/and /
/other /
/information /
/with //25 //major //diagnostic //categories //and //hundreds //of //different //subcategories
basics //rules //of //documentation //- //verified //answer(s)-
✔✔all /
/documents /
/should /
/have /
/the /
/correct //patient //name //identification //number, //date //of //birth, //date //and //time //if //appropriate
Basic //rules //for //documentation //- //verified //answer(s)-
✔✔avoid //use //of //general //empty //phases //such //as //status //unchanged //or //had //good //day
basic //rules //for //documentation //3 //- //verified //answer(s)-
✔✔be //objective //in //charting: //only //what //you //hear, //see, //feel, //smell
basic //rules //for //documentation //4 //- //verified //answer(s)-
✔✔Be //timely, //specific, //accurate, //and //complete
basic //rules //for //documentation //5 //- //verified //answer(s)-
✔✔Chart //after //Care //is //provided, //not //before
, basic //rules //for //documentation //6 //- //verified //answer(s)-
✔✔chart //all //ordered //careas //given //or //explain //the //deviation, //ex. //NPO, //nothing //by //mouth,
//for //laboratory, //off //unit, //refused
basic //rules //for //documentation //7 //- //verified //answer(s)-
✔✔chart //as //soon //and //as //often //as //necessary
basic //rules //for //documentation //8 //- //verified //answer(s)-
✔✔Chart //facts //avoid //judgmental //terms //and //placing //blame.
basic //rules //for //documentation //9 //- //verified //answer(s)-
✔✔Chart //only //your //own //care, //observations, //and //teaching, //never //chart //for //anyone //else.
basic //rules //for //documentation //10 //- //verified //answer(s)-✔✔Describe //each //item //as //you //see
//it
Basic //rules //for //Documentation //11 //- //verified //answer(s)-
✔✔Document /
/only //what //you //observe //not //opinions, //never //use //charging //to //accuse //someone //else
Basic //rules //for //documentation //12 //- //verified //answer(s)-
✔✔Fill /
/all //spaces //leave //no //empty //lines //chart //consecutively //go //line //by //line //do //not //Left //margin.
Basic //rules //for //documentation //13 //- //verified //answer(s)-
✔✔Follow //each //institution's //policy //and //procedures //for //charting
Basic //rules //for //documentation //14 //- //verified //answer(s)-
✔✔Follow //rules //of //grammar //and //punctuation
108
/ /
Final Exam Questions With Correct Answers
/ // // // // //
intervention //- //verified //answer(s)-✔✔care //provided //to //improve //a //situation
Charting, //recording, //documenting //- //verified //answer(s)-
✔✔the //Process //of //adding //information //to //a //chart //is //called
Documentation //- //verified //answer(s)-
✔✔an /
/integral /
/part /
/of /
/the /
/implementation /
/phase /
/of /
/the /
/nursing /
/process /
/and /
/is /
/necessary /
/for //the //evaluation //of //patient //care //and //for //reimbursement //for //the //cost //of //care //provided
DRG //- //verified //answer(s)-
✔✔diagnostic /
/related /
/group //
a/
,/group /
/that /
/classifies /
/patients /
/by /
/age, /
/diagnosis, /
/surgical /
/procedure, /
/and /
/other /
/information /
/with //25 //major //diagnostic //categories //and //hundreds //of //different //subcategories
basics //rules //of //documentation //- //verified //answer(s)-
✔✔all /
/documents /
/should /
/have /
/the /
/correct //patient //name //identification //number, //date //of //birth, //date //and //time //if //appropriate
Basic //rules //for //documentation //- //verified //answer(s)-
✔✔avoid //use //of //general //empty //phases //such //as //status //unchanged //or //had //good //day
basic //rules //for //documentation //3 //- //verified //answer(s)-
✔✔be //objective //in //charting: //only //what //you //hear, //see, //feel, //smell
basic //rules //for //documentation //4 //- //verified //answer(s)-
✔✔Be //timely, //specific, //accurate, //and //complete
basic //rules //for //documentation //5 //- //verified //answer(s)-
✔✔Chart //after //Care //is //provided, //not //before
, basic //rules //for //documentation //6 //- //verified //answer(s)-
✔✔chart //all //ordered //careas //given //or //explain //the //deviation, //ex. //NPO, //nothing //by //mouth,
//for //laboratory, //off //unit, //refused
basic //rules //for //documentation //7 //- //verified //answer(s)-
✔✔chart //as //soon //and //as //often //as //necessary
basic //rules //for //documentation //8 //- //verified //answer(s)-
✔✔Chart //facts //avoid //judgmental //terms //and //placing //blame.
basic //rules //for //documentation //9 //- //verified //answer(s)-
✔✔Chart //only //your //own //care, //observations, //and //teaching, //never //chart //for //anyone //else.
basic //rules //for //documentation //10 //- //verified //answer(s)-✔✔Describe //each //item //as //you //see
//it
Basic //rules //for //Documentation //11 //- //verified //answer(s)-
✔✔Document /
/only //what //you //observe //not //opinions, //never //use //charging //to //accuse //someone //else
Basic //rules //for //documentation //12 //- //verified //answer(s)-
✔✔Fill /
/all //spaces //leave //no //empty //lines //chart //consecutively //go //line //by //line //do //not //Left //margin.
Basic //rules //for //documentation //13 //- //verified //answer(s)-
✔✔Follow //each //institution's //policy //and //procedures //for //charting
Basic //rules //for //documentation //14 //- //verified //answer(s)-
✔✔Follow //rules //of //grammar //and //punctuation
