Nokea
Indicate whether the following statements are True (T) or False (F). When documenting patient teaching, the only thing that must be included is the subject that was taught and the methods used to teach the subject.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Documentation should also include patient understanding and response to teaching.
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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.
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.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following is(are) a purpose of documentation?
- A. To provide a record for administration to prove that the nurses have earned their pay
- B. To provide a permanent record of medical diagnoses, nursing diagnoses, plan of care, care provided, and the patient's response to that care
- C. To serve as a punitive measure for nurses who will not do all the interventions
- D. To serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes
Correct Answer: B,D
Rationale: Documentation serves as a permanent record of patient care (B) and supports accountability for quality assurance, accreditation, and reimbursement (D). A is incorrect as documentation is not about proving nurses' pay, and C is incorrect as it is not a punitive measure.
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.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When documenting with focus charting, which acronym is generally used?
- A. SOAP
- B. SOAPIER
- C. PIE
- D. DAR
Correct Answer: D
Rationale: Focus charting uses the DAR (Data, Action, Response) acronym (D). SOAP (A), SOAPIER (B), and PIE (C) are used in other charting methods.