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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When documenting with focus charting, which acronym is generally used?
- A. SOAP
- B. SOAPIER
- C. PIE
- D. DAR
Correct Answer: D
Rationale: Focus charting uses the DAR (Data, Action, Response) acronym (D). SOAP (A), SOAPIER (B), and PIE (C) are used in other charting methods.
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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 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.
Indicate whether the following statements are True (T) or False (F). Failure to document administration of a medication does not carry a potential legal risk.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Failing to document medication administration poses a legal risk due to potential patient harm and accountability issues.
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 are accurate statements about EHR?
- A. It is a record of the patient's interactions with the primary care doctor, but not with specialists.
- B. It is a record of an individual's lifetime health information, easily updated and transferable.
- C. It has built-in security and confidentiality, so nurses do not have to take any additional precautions.
- D. The nurse is only supposed to access the records of the patients that he or she cares for, not every patient on the nursing unit.
- E. It is only available on hand-held computers.
Correct Answer: B,D
Rationale: EHR is a lifetime health record (B) and nurses should only access assigned patients' records (D). A is false as it includes specialists, C is false as precautions are needed, and E is false as EHR is not limited to hand-held devices.