Documentation Practice Exam

Practice Mode – Questions and choices are randomly arranged, the answer is revealed instantly after each question, and there is no time limit for the exam.

Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.

1. Which of the following does not refer to the process of adding written information to a health care record?

1. Recording
2. Charting
3. Data entry
4. Documenting

2. Which of the following statements about documenting is not true?

1. Involves recording the interventions carried out to meet the patient’s needs.
2. Done in a proper way, it reflect the nursing process.
3. Necessary to prove that nursing work was done.
4. Nursing documentation can be accepted in both verbal and written form

3. Which of the following are basic purposes for an accurate and complete written patient records? Select all that apply

1. Sometimes used by government agencies to evaluate patient care
2. It is a permanent record for accountability
3. It is a legal record of care
4. They are perfect sources for business and marketing
5. Can be used for research, teaching and data collection

4. This is the main basis for cost reimbursement rates by government plans

1. Critical pathway
2. Minimum data sheet
3. Diagnoses related groups
4. Patient expense documentation

5. Which of the following statements are true regarding basic rules for documentation. Select all that apply.

1. Use direct quotes for objective assessments
2. If a charting error is made, draw one line through the faulty information
3. Chart only your own care even when someone else calls you for a late entry.
4. Chart after care is provided, as soon as possible, and as often as needed
5. Sign each block of charting with full legal initials and title

6. Based upon the legal guidelines for documentation, which of the following corrective action is incorrect?

1. Never erase entries or use correction fluid. Never right with a pencil.
2. Do not record “physician made error”.
3. Be certain that entry is factual even when opinions are used
4. While logged into the computer, do not leave terminal unattended even during an emergency.

7. Which of the following statements about common forms of inadequate documentation should not be included?

1. Not charting correct time when events occurred
2. Failing to record verbal orders or failing to have them signed
3. Documentation only in hand written format even when EMR is mandated
4. Charting actions in advance to save time
5. Documenting incorrect data

8. What kind of documentation is the following? Pain scale 0/10, hand and leg strong to right, weak to left. Skin pink, warm and dry, turgor good, incision to Rt. anterior chest wall erythema or edema ……………….Jane Night, LPN.

1. Kardex
2. Narrative
3. Nurse’s Notes
4. Shift report

9. Which of the following practices could lead to malpractice? Select all that apply

1. Charting interventions in advance to save time
2. Documenting incorrect data
3. Not charting the correct time when events took place
4. Deleting incorrect entries and crossing them out with a horizontal line.
5. Not recording verbal orders or not having them signed.

10. Charting that is divided into sections or blocks. Emphasis is placed on specific sections, or sheets of information. It also uses graphics and narrative charting

1. Traditional Chart
2. Problem-oriented medical record
3. Standard form
4. Kardex

11. Which of the following is a typical section of a traditional chart? Select all that apply

1. Admission sheet and physician’s orders
2. Progress notes and nurse’s admission information
3. History and Physical Examination Data
4. Medical Administration Record
5. Care plan and nurse’s notes

12. Which of the following is considered a traditional charting?

1. Narrative
2. Problem Oriented Medical Record
3. SOAPE
4. DARE

13.What is the difference between Traditional and Problem Oriented medical Record charting?

1. Traditional uses an abbreviated story form. POMR uses an outline form
2. Traditional uses SOAPE charting. Problems oriented medical record uses narrative charting
3. Traditional uses blocks. POMR uses sections.
4. Traditional focuses on interventions. POMR focuses on interventions.

14. Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply.

1. Database
2. Problem list
3. Care plan
4. Physical examination and diagnostic tests
5. Referral form

15. Active, inactive potential and resolved problems that serve as the index for charting documentation

1. Problem assessments
2. Problem List
3. Database
4. Traditional Chart

16. In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included?

1. It is not mentioned in this kind of documentation
2. Included in the notations under PLANNING
3. Included under assessment
4. It belongs to another format

17. In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included?

1. REVISIONS belong to another format of documentation
2. REVISIONS are not part of this documentation
3. REVISIONS are noted in the EVALUATION section
4. REVISIONS are noted in the ASSESSMENT section

18. Which of the following statements about FOCUS CHARTING is incorrect?

1. Uses the nursing process and the more positive concept of patient needs
2. Focus is sometimes a current patient concern or behavior.
3. Focus is sometimes a significant changes in patient status or behavior or a significant event in the patient’s therapy.
4. Focus can be a medical diagnosis

19. Which of the following statements regarding the DARE format of documentation are correct? Select all that apply

1. Data, action, response and evaluation, education and patient teaching
2. Data is both subjective and objective
3. Action combines planning and implementation
4. You need to use all the DARE steps each time you make notes on a particular focus
5. Response is the same as evaluation and effectiveness
6. Some facilities include education or patient teaching

20. There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Legally, care is not given if care is not charted. This is true but it is time consuming and requires excessive detail and a defensive manner in doing so. To solve this issue, what did some hospitals come up with?

1. CBE
2. DOA
3. ABC
4. APIE

21. Which of the following formats is included under Charting be exception? Select all that apply.

1. PIE
2. SOAPE
3. SOAPIER
4. APIE

22. What is the essential difference between PIE and SOAPE formats?

1. PIE is from a nursing process. SOAPE is from a medical model
2. PIE is from a medical model. SOAPE is from a nursing process
3. PIE and SOAPE are both used for charting by exception
4. PIE and SOAPE both emerge from the nursing process

23. What kind of notes are taken when charting by exception? Select all that apply.

1. Additional treatments done or planned treatments withheld
2. Standing orders and physical history
3. New Concerns
4. Changes in patient condition

24. In charting by exception, what happens after the patient’s problem is resolved?

1. It needs to be a part of the SOAPE documentation
2. It needs to be explained to the next shift
3. It is no longer covered by daily documentation
4. It needs to be transferred to a permanent record

25. Which of the following are considered examples of record keeping forms? Select all that apply.

1. Kardex or Rand
2. Nursing Care Plan
3. Incident Reports
4. 24-hour patient care and acuity charting
5. Discharge summary

26. A system used to consolidate patient orders and care needs in a centralized, concise way.

1. Incident Reports
2. Kardex or Rand System
3. Intervention Guidelines
4. Nursing Care plan

27. Preprinted guidelines used to care for patients with similar health problems.

1. Nursing Care Plan
2. Kardex
3. Common illness index
4. Health intervention reference

28. Developed by nurses for nurses, it is based on nursing diagnoses and nursing assessment. It also includes, goals, plans for care and specific actions for care implementation and evaluation

1. Standardized nursing care plans
2. Plans written in nursing notes
3. Narrative planning
4. Kardex or Rand

29. What do you have to fill up when an event transpired is not consistent with routine operation of a health care unit or routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care. These events have the potential to cause injury.

1. Injury reports
2. Incident reports
3. Intervention reports
4. Implementation reports

30. Which of the following should not be considered when filling up an incident report?

1. Do not admit liability or give unnecessary details
2. List date, time and care given to the patient and the name of the Physician notified.
3. Personal assessment and judgment of incident
4. When charting the incident in the patient’s nursing notes, do not mention the incident report.

31. Benefits of a 24-hour patient care records. Select all that apply:

1. Helps eliminate unnecessary record keeping forms
2. Enhances efficiency because flow sheets and checklists are often used.
3. Accommodates a 24-hour period
4. Necessary to maintain a good nursing care plan

32. Uses a score that rates each patient by severity of illness.

1. Acuity charting
2. Charting by exception
3. Critical pathway
4. Traditional Charting

33. One of the benefits of acuity charting is that it provides us with the ability to determine efficient staffing patterns according to the acuity levels of the patients on a particular nursing unit.

1. True
2. False

34. When does discharge planning ideally begin?

1. During admission
2. After admission
3. Before admission
4. Without admission

35. A systematic approach to care that provides a framework for the coordination of medical and nursing interventions.

1. Managed care
2. Critical pathway
3. Acuity Care
4. Intensive care

36. Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply:

1. Allows staff to develop standardized integrated care plans for a projected length of stay for patients of a specific case type.
2. Clinical pathways that delve with cases occur in high volume and are predictable.
3. The clinical pathway replaces other nursing forms such as the nursing care plans
4. Charting by exception is usually the method used for clinical pathways
5. The exact contents and format of these clinical pathways are the same among different institutions.

37. Which of the following statements about home health care are true? Select all that apply

1. It provides a narrower scope of people for a wider majority of services.
2. Requires a whole health care team to work closely
3. Does not demand meticulous and thorough documentation
4. Duplication of documentation is difficult to avoid

38. Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities

1. MDS
2. DRG
3. BCG
4. NCLEX

39. An irate patient tells a clerk, “I have paid too much every time I came to this clinic for a physical examination. I think my medical records belong to me. I need them now”. What would be the best response.

1. I am required to give you a request form so that I can prove you wanted your records and not just anyone else.
2. Your original health care record belongs to the Physician.
3. One moment, let me make a copy of it immediately. How many do you want?
4. I am so sorry but you really do not have a right to look at your own records.

40. Patients usually do not have immediate access to their full records. There is one exception. What is it?

1. County hospitals such as Stroger’s Hospital
2. University clinics such as PCCTI Nursing lab
3. Federal Health Care Agencies such as VA hospitals
4. Municipal Health Care Centers such as Oakbrook Health Center

41. What does HIPAA mandate health care personnel with regards to patient’s records?

1. Privacy
2. Accessibility
3. Confidentiality
4. Availability

42. What do Electronic Medical Records require from the health care personnel?

1. Log into the system with a secure password
2. Log into the system with a common password
3. Log into the system with a borrowed password
4. Log into the system with a friend’s password

43. The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:

1. Documentation by the nurse
2. Appropriate physician progress notes
3. Diagnosis-related groups
4. Minimum data sheets

44. While doing clinicals, your nurse preceptor had to leave her station immediately due to a code overheard on the public address system. You observed that the computer monitor displayed a patients medical history. This patient was not assigned to your care. What should you do next?

1. Read the medical history for your own education.
2. Turn off the computer as soon as possible
3. Print the document to serve as future reference
4. Call your clinical instructor and ask what to do

45. When is it unnecessary to chart a narrative note? Select all that apply.

1. Each time you give a medication
2. Each time a bath is given
3. Each time a decubitus ulcer changes in appearance
4. Each time you assess vital signs

Answers

1. C. Data entry

2. D. Nursing documentation can be accepted in both verbal and written form.

3. A,B,C,E.

4. C. Diagnoses related groups

5. B,C,D. Use direct quotes for subjective assessment. Sign each block of charting with full initials and title.

6. C. Be certain that entry is factual even when opinions are used.

7. C. Documentation only in hand written format even when EMR is mandated

8. B. Narrative

9. A,B,C, E.

10. A. Traditional Chart

11. A,B,D,E

12. A. Narrative

13. A. Traditional uses an abbreviated story form. POMR uses an outline form

14. A,B,C,D

15. B. Problem List

16. B.  Included in the notations under PLANNING

17. C. REVISIONS are noted in the EVALUATION section

18. D. Focus can be a medical diagnosis

19. A,B,C,E,F

20. A. CBE

21. A,D

22. A. PIE is from a nursing process. SOAPE is from a medical model

23. A,C,D

24. C. It is no longer covered by daily documentation

25. A,B,C,D,E

26. B. Kardex or Rand System

27. A. Nursing Care Plan

28. A. Standardized nursing care plans

29. B. Incident reports

30. C. Personal assessment and judgment of incident

31. A,B,C.

32. A. Acuity charting

33. A. True

34. A. During admission

35. A. Managed care

36. A,B,C,D

37. A,B,D

38. A. MDS

39. A. I am required to give you a request form so that I can prove you wanted your records and not just anyone else.

40. C. Federal Health Care Agencies such as VA hospitals

41. C. Confidentiality

42. A. Log into the system with a secure password

43. C. Diagnosis-related groups

44. B. Turn off the computer as soon as possible. It is the ethical thing to do to show respect to patient’s confidentiality.

45. A,B,D.