Nokea
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Occurrences that should be documented on an incident report form include some of the following. Which ones are included?
- A. A patient fall
- B. A medication error
- C. A 1/4-inch scrape on a visitor's leg from brushing the leg against the edge of the wheelchair
- D. A lack of supplies needed to perform a procedure
- E. A nursing assistant bumped her head on the television mounted on the wall
- F. An unsafe staffing situation for the number and type of patients on the unit
Correct Answer: A,B,E,F
Rationale: Incident reports are needed for patient falls (A), medication errors (B), staff injuries (E), and unsafe staffing (F). Minor visitor scrapes (C) and supply issues (D) are typically not reported.
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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.
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.
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. 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. 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.