Chapter 5 Documentation

Chapter 5  Documentation

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is educating a student nurse about documentation. The nurse recognizes that additional teaching is required when the student nurse states,
A.
“Documentation serves as a temporary part of the medical record.”
B.
“Documentation is one of the most important tasks that I’ll perform in nursing.”
C.
“Documentation is the act of charting pertinent information related to a patient.”
D.
“Documentation is evidence of what transpired during an event requiring medical care.”

____ 2. When documenting in a patient’s chart, the nurse recognizes that
A.
Documentation serves as a temporary part of the medical record.
B.
Documentation is one of the least important tasks performed in nursing.
C.
Documentation is the act of charting only abnormal information related to a patient.
D.
Documentation is evidence of what transpired during an event requiring medical care.

____ 3. The nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states,
A.
“The purpose of written documentation is to communicate pertinent data to the health care team.”
B.
“The purpose of written documentation is to serve as a record of accountability for accreditation.”
C.
“The purpose of written documentation is to serve as a legal record for the health care provider only.”
D.
“The purpose of written documentation is to serve as a record of accountability for quality assurance.”

____ 4. The nurse educates a nursing student about effective patient care. The nurse recognizes that additional instruction is needed when the nursing student states,
A.
“For patient care to be effective, it must be delivered periodically.”
B.
“For patient care to be effective, it must be delivered continuously.”
C.
“For patient care to be effective, it must be evaluated continuously.”
D.
“For patient care to be effective, it must be delivered systematically.”

____ 5. A hospitalized patient tells the nurse that he wishes to take the original chart copy of his medical record home. The nurse’s best response is:
A.
“You may not have it because it belongs to your physician.”
B.
“It is your medical record and you are allowed to take it home.”
C.
“It is against hospital policy for you to look at your medical record.”
D.
“You are allowed to have a copy of your medical record to take home.”

Chapter 5. Documentation
Answer Section

MULTIPLE CHOICE

1. ANS: A

Feedback
A
Documentation is a written account of patient care that will be maintained in a chart to serve as a permanent medical record. Chapter Objective: Explain four purposes of written documentation.
B
Documentation is one of the most important tasks that the nurse performs on a daily basis.
C
Documentation is the act of charting or making written notation of all of the things that are pertinent to each patient for which the nurse provides care.
D
Documentation is evidence of what transpired during a specific condition or event requiring medical care.

PTS: 1 REF: Chapter: 5 | Page: 80 OBJ: Chapter Objective: 5-2
KEY: Content Area: Documentation| Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

2. ANS: D

Feedback
A
Documentation is a written account of patient care that will be maintained in a chart to serve as a permanent medical record.
B
Documentation is one of the most important tasks that the nurse performs on a daily basis.
C
Documentation is the act of charting or making written notation of all of the things that are pertinent to each patient for which the nurse provides care.
D
Documentation is evidence of what transpired during a specific condition or event requiring medical care. Chapter Objective: Explain four purposes of written documentation.

PTS: 1 REF: Chapter: 5 | Page: 80 OBJ: Chapter Objective: 5-2
KEY: Content Area: Documentation | Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

3. ANS: C

Feedback
A
One of the purposes of written documentation is to communicate pertinent data that all health care team members need to provide continuity of care.
B
One of the purposes of written documentation is to serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes.
C
One of the purposes of written documentation is to serve as a legal record for both the patient and the health care provider. Chapter Objective: Explain four purposes of written documentation.
D
One of the purposes of written documentation is to serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes.

PTS: 1 REF: Chapter: 5 | Page: 80 OBJ: Chapter Objective: 5-2
KEY: Content Area: Documentation | Integrated Process: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

4. ANS: A

Feedback
A
For patient care to be effective, it must be delivered and evaluated continuously (not periodically). Chapter Objective: Explain four purposes of written documentation.
B
For patient care to be effective, it must be delivered and evaluated continuously.
C
For patient care to be effective, it must be delivered and evaluated continuously. Feedback 4: For patient care to be effective, it must be delivered and evaluated continuously, systematically, and smoothly from one hour to the next, including through the staffing changes between shifts.
D
For patient care to be effective, it must be delivered and evaluated continuously, systematically, and smoothly from one hour to the next, including through the staffing changes between shifts.

PTS: 1 REF: Chapter: 5 | Page: 81 OBJ: Chapter Objective: 5-2
KEY: Content Area: Patient Care | Integrated Process: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

5. ANS: D

Feedback
A
The original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility. All of the information within the chart belongs to the patient. The patient is guaranteed by HIPAA (Health Insurance Portability and Accountability Act) the right to view and obtain a copy of the medical record, but the patient does not have the right to take the original chart copy itself. HIPAA ensures the patient’s right not only to view and copy his or her own medical record, but also to amend his or her own health information.
B
The original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility. All of the information within the chart belongs to the patient. The patient is guaranteed by HIPAA the right to view and obtain a copy of the medical record, but the patient does not have the right to take the original chart copy itself. HIPAA ensures the patient’s right not only to view and copy his or her own medical record, but also to amend his or her own health information.
C
The original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility. All of the information within the chart belongs to the patient. The patient is guaranteed by HIPAA the right to view and obtain a copy of the medical record, but the patient does not have the right to take the original chart copy itself. HIPAA ensures the patient’s right not only to view and copy his or her own medical record, but also to amend his or her own health information.
D
The original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility. All of the information within the chart belongs to the patient. The patient is guaranteed by HIPAA the right to view and obtain a copy of the medical record, but the patient does not have the right to take the original chart copy itself. HIPAA ensures the patient’s right not only to view and copy his or her own medical record, but also to amend his or her own health information. Chapter Objective: Explain four purposes of written documentation.

PTS: 1 REF: Chapter: 5 | Page: 82 OBJ: Chapter Objective: 5-2
KEY: Content Area: Medical Record | Integrated Process: Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis