Chapter 7 Assessment and Documentation for Optimal Care

Chapter 7  Assessment and Documentation for Optimal Care

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Which option is not a primary reason that documentation is important?
a.
Documentation enables the team to provide care to meet a resident’s individual needs.
b.
Documentation helps defend the nurse in the event of a possible lawsuit.
c.
Documentation enables a patient to receive consistent care from one shift to the next.
d.
Documentation is the basis for reimbursement to the facility.

ANS: B
Although providing a defense in the event of a possible lawsuit should not be the primary motive for the nurse to keep accurate and thorough documentation, doing so is the best defense in the event of legal action against anyone involved in a patient’s care. Enabling the team to provide care that meets individual needs is a primary reason; documentation is necessary to ensure that the team has accurate and complete information about the resident’s specific conditions. Enabling the patient to receive consistent care is a primary reason; documentation enables nurses on later shifts to be aware of conditions that have developed and the actions that have been taken on previous shifts. Providing the basis for reimbursement is a primary reason; the use of standard documentation in applying for reimbursement is a matter of law.

PTS: 1 DIF: Understand REF: 20-21
TOP: Communication and Documentation
MSC: Safe, Effective Care Environment

2. What is a SOAP note?
a.
Record of supplies used in patient hygiene
b.
Record of an event during a patient’s stay, formatted according to the Simple Object Access Protocol (SOAP), enabling it to be easily transmitted between computers
c.
Form of bar code
d.
Record of patient data listing the patient’s subjective complaint, objective data recorded by the nurse, the nurse’s assessment of the situation, and the nurse’s plan of action

ANS: D
SOAP stands for subjective (patient complaint), objective (observed data), assessment, and plan. A SOAP note is a record of an event in which a patient makes a subjective complaint and the nurse observes objective data, makes an assessment on the basis of the complaint and the data, and makes a plan for interventions based on the assessment. A SOAP note is a record in human language describing a problem, its assessment, and planned interventions.

PTS: 1 DIF: Remember REF: 22
TOP: Communication and Documentation
MSC: Safe, Effective Care Environment

3. Which of the following is a true statement about documentation?
a.
Nurses should keep records of patients’ wishes.
b.
Patients do not have access to their own medical records.
c.
The Outcomes and Assessment Information Set (OASIS) is a complete record of the health status of a patient.
d.
The nurse is responsible for completing all of the Minimum Data Set (MDS).

ANS: A
Entering patients’ expressed wishes in the medical or clinical record helps ensure that the interdisciplinary team respects these wishes. According to regulations after the enactment of the Health Insurance Portability and Accountability Act (HIPAA), the patient has access to his or her own medical records and may designate others to have access. The OASIS is used to measure outcomes for quality improvement purposes; it does not contain all of the necessary information for care, such as vital signs. The MDS should be completed jointly by all members of the interdisciplinary team.

PTS: 1 DIF: Understand REF: 21
TOP: Communication and Documentation
MSC: Safe, Effective Care Environment

4. Which one of the following is connected with the nursing home reform mandated by a 1987 law?
a.
Resident Assessment Instrument (RAI)
b.
HIPAA
c.
OASIS
d.
Fulmer SPICES

ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an assessment designed for use in the home health care setting. Fulmer SPICES is an overall assessment tool developed in 2007.

PTS: 1 DIF: Remember REF: 26| 19
TOP: Communication and Documentation
MSC: Safe, Effective Care Environment