Nokea
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following is(are) a purpose of documentation?
- A. To provide a record for administration to prove that the nurses have earned their pay
- B. To provide a permanent record of medical diagnoses, nursing diagnoses, plan of care, care provided, and the patient's response to that care
- C. To serve as a punitive measure for nurses who will not do all the interventions
- D. To serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes
Correct Answer: B,D
Rationale: Documentation serves as a permanent record of patient care (B) and supports accountability for quality assurance, accreditation, and reimbursement (D). A is incorrect as documentation is not about proving nurses' pay, and C is incorrect as it is not a punitive measure.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of these following types of data should be included in weekly summaries in a long-term care facility?
- A. Use of prosthesis
- B. Activity level
- C. Length of time the resident has been at the facility
- D. Whether continent or incontinent of bowel and bladder
- E. Whether the resident can speak
- F. Whether the resident routinely has relatives and visitors
- G. Social activities in which the resident participates
Correct Answer: A,B,D,E,F,G
Rationale: Weekly summaries should include prosthesis use (A), activity level (B), continence (D), speech ability (E), visitors (F), social activities (G), self-care ability (I), and diet (J). Length of stay (C), staff conflicts (H), and payment status (K) are not typically included.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. What time would the military time 2210 be?
- A. 10:22 a.m.
- B. 10:22 p.m.
- C. 2:21 a.m.
- D. 10:10 p.m.
Correct Answer: B
Rationale: 2210 in military time is 10:22 p.m. (B), as it is 10 minutes past 10 p.m. 10:22 a.m. (A) is 1022, 2:21 a.m. (C) is 0221, and 10:10 p.m. (D) is 2210.
Indicate whether the following statements are True (T) or False (F). If your cursive writing is not legible, you must print your documentation on a paper chart.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Legibility is critical, so printing is required if cursive is unreadable.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
- A. Charting in code
- B. Logging off
- C. Charting in privacy
- D. Signing on with a password
Correct Answer: B
Rationale: Logging off (B) prevents unauthorized access and alterations. Charting in code (A) is not standard, privacy (C) is important but not preventive, and passwords (D) are for access, not alteration prevention.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statement(s) regarding a patient's hospital medical record is(are) accurate?
- A. All the information within the chart belongs to the patient.
- B. Access to a patient's medical record is restricted to the physician, the nurse, and the patient.
- C. HIPAA guarantees the patient the right to view his or her own medical record.
- D. The patient may not take the original medical record because it is the property of the hospital.
- E. The medical record belongs to the admitting physician.
- F. The hospital must provide the patient with a written explanation of how the patient's health information will be used.
- G. The patient has the right to a copy of any or all of his or her own medical records.
Correct Answer: C,D,F,G
Rationale: HIPAA ensures patient access to records (C), originals are hospital property (D), hospitals must explain health information use (F), and patients can get copies (G). A is false as information is owned by the hospital, B is false as others may access records, and E is false as records are not owned by physicians.