Nokea
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statements is(are) true in reference to The Joint Commission?
- A. The Joint Commission audits medical records to verify facility compliance in meeting established healthcare standards.
- B. The Joint Commission sets the standards by which the quality of health care is measured nationally and internationally.
- C. The Joint Commission seeks to improve safety and quality of care that health-care organizations provide to the public.
- D. The Joint Commission is a group of commissioned individuals who collectively represent all the medical insurance companies who set the standards for medical care reimbursement.
Correct Answer: A,B,C
Rationale: The Joint Commission audits records (A), sets healthcare quality standards (B), and aims to improve safety and quality (C). D is incorrect as it does not represent insurance companies.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. The correct signature for documentation includes which of the following?
- A. First and last names
- B. First name, last initial, and credentials
- C. First initial, middle initial, last initial, and credentials
- D. First name, middle name, and last name
- E. First initial, last name, and credentials
Correct Answer: A,E
Rationale: Correct signatures include first and last names (A) or first initial, last name, and credentials (E). B, C, and D do not meet standard documentation requirements.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following charting 'omissions' (meaning they were not charted) would carry potential legal risks just by the nature of the omission?
- A. The time a patient consumed his or her evening meal
- B. A rash and swelling noted during assessment
- C. The fact that the patient has a history of hemophilia
- D. A physician's order for a medication
- E. The nurse instructed the patient that he needs to increase oral intake
- F. Noting of a physician's order to make a patient NPO
Correct Answer: B,C,D,F
Rationale: Omitting a rash/swelling (B), hemophilia history (C), medication order (D), or NPO order (F) poses legal risks due to potential harm. Meal time (A) and oral intake instruction (E) are less critical.
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.
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.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of these following are sections of a source-oriented chart?
- A. Database
- B. Graphic sheet
- C. Laboratory
- D. Medication administration record
- E. Nurse's notes
- F. Physician's progress notes
Correct Answer: A,B,C,D,E,F
Rationale: Source-oriented charts include database (A), graphic sheet (B), laboratory (C), medication administration record (D), nurse's notes (E), and physician's notes (F), as they are standard sections for organizing patient data.