Chapter 13 Documentation And Informatics

Chapter 13  Documentation And Informatics

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. While documenting on a client’s medical record, the nurse realizes that it is a legal document and should include all of the following, EXCEPT:
a.
be time sequenced.
c.
use authorized abbreviations.
b.
use proper spelling and grammar.
d.
be typed.

ANS: D
The legal issues of documentation require legible and neat writing on paper records, the proper use of spelling and grammar, the use of authorized abbreviations, and documentation that is factual and time sequenced. Documentation in a client’s medical record does not need to be typed.

PTS: 1 DIF: Application REF: Legal and Practice Standards

2. The nurse who forgets to document an element of clinical significance and recalls it later should:
a.
not add this information to the chart as it will be out of sequence.
b.
add this information to the original entry and initial it.
c.
rewrite the original entry.
d.
include this information, dating and signing the additional material.

ANS: D
When the nurse forgets to document significant data, it is appropriate and advisable to include this data at a later date. The data should include a date and signature. The other choices are incorrect and should not be done.

PTS: 1 DIF: Application REF: Organization

3. The nurse notes a significant change in the client’s condition. The nurse should:
a.
notify the physician and document the change and the notification of the physician in the chart.
b.
document the change in the chart.
c.
notify the physician and chart that the physician was notified.
d.
chart the change and notify the nursing supervisor.

ANS: A
The nurse should notify the physician of any change in a client’s condition and document the client’s change and the notification of the physician in the client’s chart. The nurse should not only document the change in the chart or only notify the physician and chart that the physician was notified. The nurse does not need to notify the nursing supervisor with a change in a client’s condition.

PTS: 1 DIF: Application REF: General Documentation Guidelines

4. The nurse is attending an in-service education program that identifies the Joint Commission’s requirements of documentation. Which of the following would be one of these requirements?
a.
A traditional nursing care plan
b.
Documentation of all steps of the nursing process
c.
Interdisciplinary planning and implementation of all aspects of care
d.
Client signature on nursing records

ANS: C
The Joint Commission requires: 1) the involvement of the client in the development of the plan of care, which must be documented in the medical record, and 2) that interdisciplinary planning and implementation of all aspects of care occur. The other choices are not requirements by the Joint Commission regarding documentation.

PTS: 1 DIF: Analysis
REF: The Joint Commission on Accreditation of Healthcare Organizations (TJC)

5. The nurse makes a mistake when charting on the client’s record. To correct this mistake the nurse should:
a.
white-out the mistake and make the correct entry.
b.
blot out the error with ink and make the correct entry.
c.
draw a line through the error, sign, and date the correction.
d.
leave the error intact and chart the correction immediately following the error.

ANS: C
If an error is made while documenting, use a single line to cross out the error, then date, time, and sign the correction. The nurse should not white-out the mistake, blot out the error with ink, or leave the error intact and chart only the correction.

PTS: 1 DIF: Application REF: General Documentation Guidelines