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1. Which of the following does not refer to the process of adding written information to a health care record? 2. Which of the following statements about documenting is not true? 3. Which of the following are basic purposes for an accurate and complete written patient records? Select all that apply 4. This is the main basis for cost reimbursement rates by government plans 5. Which of the following statements are true regarding basic rules for documentation. Select all that apply. 6. Based upon the legal guidelines for documentation, which of the following corrective action is incorrect? 7. Which of the following statements about common forms of inadequate documentation should not be included? 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. 9. Which of the following practices could lead to malpractice? Select all that apply 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 11. Which of the following is a typical section of a traditional chart? Select all that apply 12. Which of the following is considered a traditional charting? 13.What is the difference between Traditional and Problem Oriented medical Record charting? 14. Which of the following are considered the principal sections of a problem-oriented medical record? Select all that apply. 15. Active, inactive potential and resolved problems that serve as the index for charting documentation 16. In the SOAPE format, a briefer adaptation of the POMR, where is Intervention (I) included? 17. In the SOAPE format, if ever there is a need for changes, where will the REVISIONS (R) be included? 18. Which of the following statements about FOCUS CHARTING is incorrect? 19. Which of the following statements regarding the DARE format of documentation are correct? Select all that apply 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? 21. Which of the following formats is included under Charting be exception? Select all that apply. 22. What is the essential difference between PIE and SOAPE formats? 23. What kind of notes are taken when charting by exception? Select all that apply. 24. In charting by exception, what happens after the patient’s problem is resolved? 25. Which of the following are considered examples of record keeping forms? Select all that apply. 26. A system used to consolidate patient orders and care needs in a centralized, concise way. 27. Preprinted guidelines used to care for patients with similar health problems. 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 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. 30. Which of the following should not be considered when filling up an incident report? 31. Benefits of a 24-hour patient care records. Select all that apply: 32. Uses a score that rates each patient by severity of illness. 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. 34. When does discharge planning ideally begin? 35. A systematic approach to care that provides a framework for the coordination of medical and nursing interventions. 36. Which of the following statements about Clinical (Critical Pathway) are true? Select all that apply: 37. Which of the following statements about home health care are true? Select all that apply 38. Required by the Omnibus Budget Reconciliation Act primarily for Long Term Care facilities 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. 40. Patients usually do not have immediate access to their full records. There is one exception. What is it? 41. What does HIPAA mandate health care personnel with regards to patient’s records? 42. What do Electronic Medical Records require from the health care personnel? 43. The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on: 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? 45. When is it unnecessary to chart a narrative note? Select all that apply. 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. Practice Mode
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Documentation Practice Exam
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