Nokea
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Guidelines for paper documentation include which of the following?
- A. All documentation for your shift must be signed after you have charted your last entry for the shift.
- B. All documentation must be done in cursive writing.
- C. Charting should be done in blocks of time to reduce the number of unnecessary entries.
- D. The date and time should be included with each entry.
Correct Answer: A,D
Rationale: Paper documentation requires signing at shift's end (A) and including date/time (D). Cursive is not mandatory (B), and block charting (C) is not standard.
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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 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.
Indicate whether the following statements are True (T) or False (F). An advantage of computerized documentation is that it is easy to read.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Computerized documentation is typically legible, reducing errors from handwriting.
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.
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.
Indicate whether the following statements are True (T) or False (F). In charting by exception, normal findings are not charted and checklists are used for routine care.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Charting by exception focuses on abnormal findings, using checklists for routine care.