Nokea
In a source-oriented medical record, which of these would be found in the Nurse's Notes section?
- A. Nurse's assessment data
- B. HCP's assessment data
- C. Patient's response to initiation of IV therapy
- D. Patient's living will
- E. Report of chest x-ray results
- F. Patient's complains of incisional pain
Correct Answer: A, C, F
Rationale: Nurse's Notes include nurse assessments, patient responses, and patient complaints, not HCP data, living wills, or diagnostic reports.
You may also like to solve these questions
Which document would be found in the Advanced Directive section of a source-oriented medical record?
- A. Signed surgical consent
- B. Living will
- C. Discharge plans
- D. Treatment plan for the diagnosis
Correct Answer: B
Rationale: The Advance Directive section contains documents like living wills, which outline patient preferences for care.
When working in long-term care, the nurse is required to document assessment data on a resident how often?
- A. Every 2 hours
- B. Every 24 hours
- C. Every week
- D. Every month
Correct Answer: D
Rationale: In long-term care, resident assessments are typically documented monthly unless otherwise specified.
Which of the following phrases are written objectively?
- A. Ate 45% full-liquid diet. Did not act very hungry and acted like she should not have drunk all that she did.'
- B. Complaining of really severe pain and wants something for it.'
- C. Ambulated unassisted the length of hallway without complaints of fatigue or shortness of breath.'
- D. Does not feel good today. Angry and depressed.'
- E. Makes good eye contact, smiling. States feels 'much better today than yesterday.'
Correct Answer: C, E
Rationale: Objective phrases describe observable facts, like ambulation or specific patient statements, without subjective interpretation.
When you use an EHR, you may enter information in which of the following ways?
- A. Hand-held computer
- B. Computer at a computer station in the hallway
- C. Computer at the nurses' station
- D. Bedside terminal in the patient's room
- E. Your personal laptop wherever it is convenient
Correct Answer: A, B, C, D
Rationale: EHRs can be accessed via authorized devices like hand-held computers, hallway stations, nurses' stations, or bedside terminals, but personal laptops are not secure.
Which of the following times during a 7 a.m. to 7 p.m. shift would be appropriate to document on a patient's chart?
- A. As soon as possible after an occurrence or event
- B. Once at the beginning of the shift, again about midway through the shift, and the last time at the end of the shift
- C. Before the physician makes morning rounds at 10:15 a.m.
- D. Following the performance of physical assessments
- E. Not until all your patient care has been completed for the shift
- F. At least every 2 hours
Correct Answer: A
Rationale: Documentation should occur as soon as possible after an event to ensure accuracy and timeliness.