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Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following rule(s) do(es) not apply to paper documentation?
- A. Avoid leaving blank lines.
- B. Write in complete sentences using correct grammar.
- C. Capitalize the first letter of the first word of each phrase.
- D. The only subjective data that you should document are that which the patient or patient's family members may tell you verbally.
- E. Use only approved abbreviations.
- F. Attempt to accurately label the patient's behaviors with terms that are descriptive.
- G. End each phrase or sentence with a period.
Correct Answer: D
Rationale: Subjective data documentation is not limited to verbal reports (D). All other options (A, B, C, E, F, G) are standard paper documentation rules.
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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.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following entries are succinct?
- A. I took her temp and it was up to 104.2 degrees Fahrenheit.
- B. After giving a complete bed bath, oral care was performed with toothpaste, toothbrush, and mouthwash. Lotion was applied liberally over arms, back, legs, feet, and hands. Her feet and back were massaged for quite a while.
- C. 18 Fr. Foley cath inserted without difficulty & hung to gravity drainage. Returned 275 mL clear pale yellow urine.
- D. The patient said she is really nauseated badly but that she hasn't vomited yet. She asked for her nausea medication that comes in an injection.
- E. C/O constant sharp, stabbing pain in Rt. great toe, began 1 hr ago, now a 7 on 0-10 scale.
Correct Answer: C,E
Rationale: Succinct entries are the Foley catheter insertion (C) and pain complaint (E). A is informal, B is overly detailed, and D is wordy.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. You can safely delegate documentation of certain data to an unlicensed staff member. Which of the following data cannot be delegated?
- A. Administration of medication
- B. Documenting vital signs
- C. Items on a patient care flow sheet, such as type of bath, ambulation, or percentage of diet consumed
- D. Items on a patient care flow sheet, such as pm use of oxygen, that heart sounds are distinct, or presence of edema
Correct Answer: A
Rationale: Medication administration documentation (A) cannot be delegated, as it requires a licensed professional. Vital signs (B) and flow sheet items (C, D) can typically be delegated to unlicensed staff.
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 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.