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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.
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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that needs to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective.
- A. Snored loudly most of night between 0030 and 0530.
- B. Green purulent drainage increased from yesterday. ABD pad has 6' circle of drainage.
- C. Procedure tolerated well.
- D. ADA diet-ate 75% tolerated poorly.
- E. Bouncing foot almost continually. Rubbing hands and flicking finger with thumb at intervals. Verbally denies feeling nervous or anxious.
- F. Got mad while ambulating in the hall.
- G. Has a bad attitude.
Correct Answer: C,D,F,G
Rationale: Subjective terms: 'tolerated well' (C), 'tolerated poorly' (D), 'got mad' (F), 'bad attitude' (G). These should be replaced with objective descriptions. A, B, and E are objective.
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.
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. 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. Why do insurance companies review medical records?
- A. Reimbursement is dependent on documentation of specific data in the medical record.
- B. Insurance reimbursement depends on the specific consents that the patient or family members have signed.
- C. Records help insurance companies to detect problems, less-than-desirable outcomes, or areas of weakness in the delivery systems so that improvements can be made.
- D. Because the medical record is the property of the patient's insurance company.
Correct Answer: A,C
Rationale: Insurance companies review medical records for reimbursement based on documented data (A) and to identify issues for improvement (C). B is incorrect as consents are not the primary focus, and D is false as records are not owned by insurance companies.