Nokea
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.
You may also like to solve these questions
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.
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.
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). The omission of a patient's latex allergy in his medical history carries a potential legal risk.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True (T): Omitting a latex allergy can lead to harm and legal liability.
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.