Fundamentals Nursing Care Skills 2nd Edition By Ludwig Burton - Test Bank

Fundamentals Nursing Care Skills 2nd Edition By Ludwig Burton – Test Bank

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Chapter 5. Documentation

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.”

____ 6. A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n)

A. Emergency record.
B. Incident report.
C. Progress report.
D. Grievance report.

____ 7. The nurse is aware that the best method to ensure documentation accuracy is to consistently chart

A. At the completion of each shift.
B. Within 4 hours of providing care.
C. Immediately after care is provided.
D. Immediately prior to providing care.

____ 8. The nurse teaches a student nurse about what type of occurrence requires completion of an incident report. The nurse recognizes that additional instruction is warranted when the student nurse states,

A. “If my patient falls out of a chair, I will complete an incident report.”
B. “If I give the wrong medication to my patient, I will complete an incident report.”
C. “If a visitor is injured while seeing my patient, I will complete an incident report.”
D. “If my patient refuses to ambulate with physical therapy, I will complete an incident report.”

____ 9. A nurse discovers a patient lying on the floor. When completing an incident report, the nurse should write:

A. “Patient fell out of bed onto the floor.”
B. “Heard patient fall from the bed to the floor.”
C. “Patient accidentally fell out of bed onto the floor.”
D. “Found patient lying face down on the floor beside the bed.”

____ 10. A nursing instructor is educating a student nurse about military time. The time is 6:00 PM The student nurse demonstrates understanding by documenting the time as

A. 1500.
B. 1600.
C. 1700.
D. 1800.

____ 11. A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is:

A. “Average intake of clear liquid diet noted.”
B. “Patient tolerates the clear liquid diet well.”
C. “Patient swallowing clear liquids normally.”
D. “No complaints of nausea while on clear liquid diet.”

____ 12. A nursing instructor is educating a class of student nurses about patient documentation. The best example of patient documentation is:

A. States “He vomited everything he ate and drank yesterday.”
B. States “He is in excruciating pain. The pain is unrelieved by analgesics.”
C. States “The pain is getting worse. I don’t know if I can stand it or not.”
D. States “His pain is getting worse and he doesn’t know if he can stand it or not.”

____ 13. When documenting in a patient’s chart, the nurse realizes that it is the wrong patient’s chart. The nurse should

A. Write over the incorrect letters.
B. Use correction fluid to blank-out the mistaken entry.
C. Use correction tape to blank-out the mistaken entry.
D. Write “mistaken entry” and his or her initials just above incorrect entry.

____ 14. The nursing instructor observes a student nurse documenting in the wrong patient’s chart. The nursing instructor would intervene when observing the student nurse

A. Writing initials just above the incorrect entry.
B. Using a marker to blacken the incorrect entry.
C. Writing “mistaken entry” just above incorrect entry.
D. Marking a single horizontal line through the incorrect entry

____ 15. The nursing instructor educates a class of nursing students about SOAPIER charting. The nursing instructor teaches that the acronym SOAPIER stands for

A. Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision.
B. Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results.
C. Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
D. Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision.

____ 16. The nursing instructor educates a class of nursing students about a common type of focus charting known as DAR. The nursing instructor teaches that the acronym DAR stands for

A. Data, Action, Response.
B. Data, Assessment, Revision.
C. Diagnosis, Action, Response.
D. Data, Assessment, Response.

____ 17. A patient complains of left-sided chest pain radiating to the left shoulder. Using the SOAPIER method, the nurse should chart this complaint under the initial

A. S.
B. O.
C. A.
D. P.

____ 18. A patient appears anxious. The patient speaks quickly and paces the hospital halls. Using the SOAPIER method, the nurse should chart this finding under the initial

A. S.
B. O.
C. A.
D. P.

____ 19. A patient complains of feeling short of breath. His oxygen saturation level is 86%. When auscultating his lung sounds, the nurse notes wheezes and crackles throughout. The patient has a productive cough of thick green mucus. The nurse should chart these actions under the section of DAR charting that is called

A. Data.
B. Action.
C. Response.
D. Assessment.

____ 20. When a patient complains of pain, the nurse assesses the pain level and administers an analgesic. The nurse should chart these actions under the section of DAR charting that is called

A. Data.
B. Action.
C. Response.
D. Assessment.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. A nursing instructor teaches a class of nursing students about the purpose of written documentation, which includes (select all that apply):

A. To communicate pertinent data to the health care team.
B. To serve as a record of accountability for accreditation.
C. To serve as a legal record for the health care provider only.
D. To serve as a record of accountability for quality assurance.
E. To serve as a record of accountability for reimbursement purposes.
F. To provide a permanent record of medical diagnoses and nursing diagnoses.

____ 2. The staff members at a hospital are preparing for a visit from The Joint Commission. The nursing supervisor explains to the staff that The Joint Commission (select all that apply):

A. Provides a team of reviewers who ensure that standards are met.
B. Acts as an insurance company by offering reimbursement to hospitals.
C. Seeks to improve safety and quality of care that health care organizations provide to the public.
D. Offers accreditation when a facility practices in a manner that meets The Joint Commission’s standards.
E. Sends a team of reviewers who visit the facility to assess its policies, procedures, and actual performance.
F. Sets the standards by which the quality of health care is managed nationally and internationally.

____ 3. A nursing instructor is educating a group of student nurses about the Health Insurance Portability and Accountability Act (HIPAA). The nursing instructor teaches that HIPAA (select all that apply):

A. Guarantees the patient the right to view his or her medical record.
B. Guarantees the patient the right to take the original medical chart.
C. Asks the patient to specify who can obtain his or her personal health data.
D. Guarantees the patient the right to obtain a copy of his or her medical record.
E. Ensures the right of the patient to amend his or her own health information.
F. Requires hospitals to disclose the way in which the patient’s health data will be used.

____ 4. The hospital risk management team provides the nursing staff with an in-service about incident reports. The in-service should include that (select all that apply):

A. An incident report always involves the patient.
B. Incident reports are part of the patient’s medical record.
C. An incident report is also referred to as a variance report.
D. A medication error should be documented on an incident report.
E. A patient, visitor, or employee injury should be documented on an incident report.
F. An incident report is used to document out-of-the-ordinary things that happen in a facility.

____ 5. The nursing instructor teaches a class of nursing students that the problem-oriented medical record consists of the (select all that apply):

A. Database.
B. Problem list.
C. Plan of care.
D. Progress notes.
E. Incident reports.
F. Variance reports.

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

6.ANS:B

Feedback
A An emergency room record is for use with patients who present to the emergency room for care. 
B When accidents, incidents, mistakes, or out-of-the-ordinary things occur, the nurse is required to file a written incident, variance, or occurrence report. Chapter Objective: Explain four purposes of written documentation.
C A progress report indicates how the patient is progressing.
D A grievance report relates to registering a complaint to management and does not have anything to do with a patient’s accident or incident.

PTS: 1 REF: Chapter: 5 | Page: 85 OBJ: Chapter Objective: 5-2

KEY:Content Area: Incident Report | Integrated Process: Documentation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application

7.ANS:C

Feedback
A The ideal method to ensure documentation accuracy is to consistently chart immediately after care is provided, when assessment data is obtained, and any event or occurrence that has the potential to affect the patient. The nurse should never chart something before it is done, as this is fraudulent.
B The ideal method to ensure documentation accuracy is to consistently chart immediately after care is provided, when assessment data is obtained, and any event or occurrence that has the potential to affect the patient. The nurse should never chart something before it is done, as this is fraudulent.
C The ideal method to ensure documentation accuracy is to consistently chart immediately after care is provided, when assessment data is obtained, and any event or occurrence that has the potential to affect the patient. The nurse should never chart something before it is done, as this is fraudulent. Chapter Objective: Summarize 12 guidelines for documentation.
D The ideal method to ensure documentation accuracy is to consistently chart immediately after care is provided, when assessment data is obtained, and any event or occurrence that has the potential to affect the patient. The nurse should never chart something before it is done, as this is fraudulent.

PTS: 1 REF: Chapter: 5 | Page: 88 OBJ: Chapter Objective: 5-4

KEY:Content Area: Documentation | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application

8.ANS:D

Feedback
A Incident reports are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient. Occurrences that should be documented on an incident or variance report form include the following: medication error; patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as an unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care; loss of a patient’s personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment.
B Incident reports are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient. Occurrences that should be documented on an incident or variance report form include the following: medication error; patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as an unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care, loss of a patient’s personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment.
C Incident reports are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient. Occurrences that should be documented on an incident or variance report form include the following: medication error; patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as an unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care; loss of a patient’s personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment.
D Incident reports are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient. Occurrences that should be documented on an incident or variance report form include the following: medication error; patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as an unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care; loss of patient’s personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment. Chapter Objective: Explain four purposes of written documentation.

PTS: 1 REF: Chapter: 5 | Page: 85 OBJ: Chapter Objective: 5-2

KEY: Content Area: Incident Report | Integrated Process: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

9.ANS:D

Feedback
A When completing an incident report or variance report, the nurse should be objective, documenting only what he or she was able to detect with his or her senses: what he or she saw, heard, smelled, or was able to feel with his or her hands. The nurse should avoid interpreting what he or she saw or heard, such as, “Heard the patient fall from the chair to the floor.” The statement should be completely objective: “Heard loud crashing sound.” Rather than write “Patient fell out of bed,” the nurse should document only objective data, such as, “Found patient lying face down on the floor beside the bed” and “Patient reports that he fell out of bed while trying to reach his telephone.” The nurse should never document assumptions or drawn conclusions.
B When completing an incident report or variance report, the nurse should be objective, documenting only what he or she was able to detect with his or her senses: what he or she saw, heard, smelled, or was able to feel with his or her hands. The nurse should avoid interpreting what he or she saw or heard, such as, “Heard the patient fall from the chair to the floor.” The statement should be completely objective: “Heard loud crashing sound.” Rather than write “Patient fell out of bed,” the nurse should document only objective data, such as, “Found patient lying face down on the floor beside the bed” and “Patient reports that he fell out of bed while trying to reach his telephone.” The nurse should never document assumptions or drawn conclusions.
C When completing an incident report or variance report, the nurse should be objective, documenting only what he or she was able to detect with his or her senses: what he or she saw, heard, smelled, or was able to feel with his or her hands. The nurse should avoid interpreting what he or she saw or heard, such as, “Heard the patient fall from the chair to the floor.” The statement should be completely objective: “Heard loud crashing sound.” Rather than write “Patient fell out of bed,” the nurse should document only objective data, such as, “Found patient lying face down on the floor beside the bed” and “Patient reports that he fell out of bed while trying to reach his telephone.” The nurse should never document assumptions or drawn conclusions.
D When completing an incident report or variance report, the nurse should be objective, documenting only what he or she was able to detect with his or her senses: what he or she saw, heard, smelled, or was able to feel with his or her hands. The nurse should avoid interpreting what he or she saw or heard, such as, “Heard the patient fall from the chair to the floor.” The statement should be completely objective: “Heard loud crashing sound.” Rather than write “Patient fell out of bed,” the nurse should document only objective data, such as, “Found patient lying face down on the floor beside the bed” and “Patient reports that he fell out of bed while trying to reach his telephone.” The nurse should never document assumptions or drawn conclusions. Chapter Objective: Summarize 12 guidelines for documentation.

PTS: 1 REF: Chapter: 5 | Page: 85 OBJ: Chapter Objective: 5-4

KEY:Content Area: Incident Report | Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

10.ANS:D

Feedback
A Many facilities now use military time in an effort to decrease confusion between AM and PM. Military time is not difficult to learn. After 12:00 noon, for the PM hours, one must simply add 12 to the hour. The colon is no longer used and the minutes remain the same. For example, to obtain the military equivalent for 6:00 PM, add 12 to the hour. The time would be 1800.
B Many facilities now use military time in an effort to decrease confusion between AM and PM. Military time is not difficult to learn. After 12:00 noon, for the PM hours, one must simply add 12 to the hour. The colon is no longer used and the minutes remain the same. For example, to obtain the military equivalent for 6:00 PM, add 12 to the hour. The time would be 1800.
C Many facilities now use military time in an effort to decrease confusion between AM and PM. Military time is not difficult to learn. After 12:00 noon, for the PM hours, one must simply add 12 to the hour. The colon is no longer used and the minutes remain the same. For example, to obtain the military equivalent for 6:00 PM, add 12 to the hour. The time would be 1800.
D Many facilities now use military time in an effort to decrease confusion between AM and PM. Military time is not difficult to learn. After 12:00 noon, for the PM hours, one must simply add 12 to the hour. The colon is no longer used and the minutes remain the same. For example, to obtain the military equivalent for 6:00 PM, add 12 to the hour. The time would be 1800. Chapter Objective: Summarize 12 guidelines for documentation. 

PTS: 1 REF: Chapter: 5 | Page: 87 OBJ: Chapter Objective: 5-4

KEY: Content Area: Military Time | Integrated Process: Nursing Process/Implementation | Client Need: Teaching and Learning | Cognitive Level: Application

11.ANS:D

Feedback
A When documenting, the nurse should refrain from using subjective terms, such as strange, well, average, normal, bad, poor, odd, or good, because they are vague and mean different things to different people. If the nurse thinks a patient tolerated the clear liquid diet well, he or she should think of the reasons why the patient tolerated it well. Was it because the patient did not experience nausea or vomiting after consumption of the first liquids allowed following NPO? Or was it because the patient with dysphagia, or difficulty swallowing, did not choke or aspirate the liquids? Whatever caused the nurse to think the patient tolerated it well is what should be charted.
B When documenting, the nurse should refrain from using subjective terms, such as strange, well, average, normal, bad, poor, odd, or good, because they are vague and mean different things to different people. If the nurse thinks a patient tolerated the clear-liquid diet well, he or she should think of the reasons why the patient tolerated it well. Was it because the patient did not experience nausea or vomiting after consumption of the first liquids allowed following NPO? Or was it because the patient with dysphagia, or difficulty swallowing, did not choke or aspirate the liquids? Whatever caused the nurse to think the patient tolerated it well is what should be charted.
C When documenting, the nurse should refrain from using subjective terms, such as strange, well, average, normal, bad, poor, odd, or good, because they are vague and mean different things to different people. If the nurse thinks a patient tolerated the clear liquid diet well, he or she should think of the reasons why the patient tolerated it well. Was it because the patient did not experience nausea or vomiting after consumption of the first liquids allowed following NPO? Or was it because the patient with dysphagia, or difficulty swallowing, did not choke or aspirate the liquids? Whatever caused the nurse to think the patient tolerated it well is what should be charted.
D When documenting, the nurse should refrain from using subjective terms, such as strange, well, average, normal, bad, poor, odd, or good, because they are vague and mean different things to different people. If the nurse thinks a patient tolerated the clear liquid diet well, he or she should think of the reasons why the patient tolerated it well. Was it because the patient did not experience nausea or vomiting after consumption of the first liquids allowed following NPO? Or was it because the patient with dysphagia, or difficulty swallowing, did not choke or aspirate the liquids? Whatever caused the nurse to think the patient tolerated it well is what should be charted. Chapter Objective: Summarize 12 guidelines for documentation.

PTS: 1 REF: Chapter: 5 | Page: 89 OBJ: Chapter Objective: 5-4

KEY:Content Area: Documentation | Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application

12.ANS:C

Feedback
A When charting direct quotations of the patient, the nurse should use his or her exact words and place them in quotation marks. The following is a correct example of charting what the patient said: States “The pain is getting worse. I don’t know if I can stand it or not.” It would be incorrect to chart what the patient said in the following manner: States “His pain is getting worse and he doesn’t know if he can stand it or not.”
B When charting direct quotations of the patient, the nurse should use his or her exact words and place them in quotation marks. The following is a correct example of charting what the patient said: States “The pain is getting worse. I don’t know if I can stand it or not.” It would be incorrect to chart what the patient said in the following manner: States “His pain is getting worse and he doesn’t know if he can stand it or not.”
C When charting direct quotations of the patient, the nurse should use his or her exact words and place them in quotation marks. The following is a correct example of charting what the patient said: States “The pain is getting worse. I don’t know if I can stand it or not.” It would be incorrect to chart what the patient said in the following manner: States “His pain is getting worse and he doesn’t know if he can stand it or not.” Chapter Objective: Summarize 12 guidelines for documentation.
D When charting direct quotations of the patient, the nurse should use his or her exact words and place them in quotation marks. The following is a correct example of charting what the patient said: States “The pain is getting worse. I don’t know if I can stand it or not.” It would be incorrect to chart what the patient said in the following manner: States “His pain is getting worse and he doesn’t know if he can stand it or not.”

PTS: 1 REF: Chapter: 5 | Page: 91 OBJ: Chapter Objective: 5-4

KEY:Content Area: Documentation| Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application

13.ANS:D

Feedback
A The nurse should avoid trying to write over incorrect letters. This only serves to make documentation sloppy and difficult to read.
B The nurse should never use correction fluid or tape to totally blank-out the mistaken entry. 
C The nurse should never use correction fluid or tape to totally blank-out the mistaken entry. 
D Upon making an incorrect entry, the nurse should mark a single horizontal line through the incorrect word or phrase, write “mistaken entry” and his or her initials just above the incorrect words, and then proceed with the correct entry. Chapter Objective: Summarize 12 guidelines for documentation. 

PTS: 1 REF: Chapter: 5 | Page: 92 OBJ: Chapter Objective: 5-4

KEY:Content Area: Documentation | Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

14.ANS:B

Feedback
A Upon making an incorrect entry, the nurse should mark a single horizontal line through the incorrect word or phrase, write “mistaken entry” and his or her initials just above the incorrect words, and then proceed with the correct entry.
B The nurse should avoid using markers or making multiple ink marks in an effort to blacken the incorrect entry so that it cannot be read, as this may raise suspicion regarding the entry. Chapter Objective: Summarize 12 guidelines for documentation.
C Upon making an incorrect entry, the nurse should mark a single horizontal line through the incorrect word or phrase, write “mistaken entry” and his or her initials just above the incorrect words, and then proceed with the correct entry.
D Upon making an incorrect entry, the nurse should mark a single horizontal line through the incorrect word or phrase, write “mistaken entry” and his or her initials just above the incorrect words, and then proceed with the correct entry. 

PTS: 1 REF: Chapter: 5 | Page: 92 OBJ: Chapter Objective: 5-4

KEY:Content Area: Documentation | Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

15.ANS:C

Feedback
A The acronym SOAPIER stands for Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
B The acronym SOAPIER stands for Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
C The acronym SOAPIER stands for Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision. Chapter Objective: Compare PIE charting and SOAPIER charting formats.
D The acronym SOAPIER stands for Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.

PTS: 1 REF: Chapter: 5 | Page: 98 OBJ: Chapter Objective: 5-7

KEY: Content Area: SOAPIER Charting | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application

16.ANS:A

Feedback
A The acronym DAR stands for Data, Action, Response. Chapter Objective: Contrast charting by exception and focus charting.
B The acronym DAR stands for Data, Action, Response. 
C The acronym DAR stands for Data, Action, Response. 
D The acronym DAR stands for Data, Action, Response.

PTS: 1 REF: Chapter: 5 | Page: 99 OBJ: Chapter Objective: 5-8

KEY:Content Area: DAR Charting | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Application

17.ANS:A

Feedback
A The S in SOAPIER stands for subjective data. This information is verbalized by the patient, significant other, or family member. This data is influenced by the person’s own personal experiences and perspective, which is what makes it subjective. What was said can be summarized, or exact words can be placed in quotation marks. Chapter Objective: Compare PIE charting and SOAPIER charting formats.
B The O in SOAPIER stands for objective data. This is for data that is related to the problem. Objective data must be something that the nurse and others are able to discern with one of the senses.
C The A in SOAPIER stands for assessment data. When used in the context of SOAPIER Charting, assessment data means the problem that the nurse identifies after analyzing the subjective and objective data. This step is very similar to the nursing diagnosis step, also known as the patient problem step, of the nursing process.
D The P in SOAPIER stands for plan. This is the plan to resolve the patient problem, or nursing diagnosis, that the nurse has identified. It is the plan of care.

PTS: 1 REF: Chapter: 5 | Page: 96 OBJ: Chapter Objective: 5-7

KEY: Content Area: SOAPIER Charting | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

18.ANS:B

Feedback
A The S in SOAPIER stands for subjective data. This information is verbalized by the patient, significant other, or family member. This data is influenced by the person’s own personal experiences and perspective, which is what makes it subjective. What was said can be summarized, or exact words can be placed in quotation marks.
B The O in SOAPIER stands for objective data. This is for data that is related to the problem. Objective data must be something that the nurse and others are able to discern with one of the senses. Chapter Objective: Compare PIE charting and SOAPIER charting formats.
C The A in SOAPIER stands for assessment data. When used in the context of SOAPIER Charting, assessment data means the problem that the nurse identifies after analyzing the subjective and objective data. This step is very similar to the nursing diagnosis step, also known as the patient problem step, of the nursing process.
D The P in SOAPIER stands for plan. This is the plan to resolve the patient problem, or nursing diagnosis, that the nurse has identified. It is the plan of care.

PTS: 1 REF: Chapter: 5 | Page: 98 OBJ: Chapter Objective: 5-7

KEY: Content Area: SOAPIER Charting | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

19.ANS:A

Feedback
A The first part of DAR charting is data, which may contain objective or subjective data. For example, the nurse might chart subjective information that the patient’s son stated or the patient’s verbal complaint of pain. Objective data that the nurse might chart might include the results of pulse oximetry testing, vital signs, or a patient behavior that is observed. Any assessment finding that the nurse detects through use of visual, auditory, olfactory, and tactile senses would be noted under data. These entries represent the data collection and assessment stage of the nursing process. Chapter Objective: Contrast charting by exception and focus charting.
B The second part of DAR charting is action, which is where the nurse charts interventions. Examples might include teaching, repositioning, administering PRN medications, changing a dressing, or notifying the physician of an abnormal lab result. These entries reflect the planning and implementing stages of the nursing process.
C The third part of DAR charting is response, which refers to the patient’s response to the interventions and reflects the evaluation phase of the nursing process.
D Assessment is not a part of the acronym DAR.

PTS: 1 REF: Chapter: 5 | Page: 99 OBJ: Chapter Objective: 5-8

KEY:Content Area: DAR Charting | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

20.ANS:B

Feedback
A The first part of DAR charting is data, which may contain objective or subjective data. For example, the nurse might chart subjective information that the patient’s son stated or the patient’s verbal complaint of pain. Objective data that the nurse might chart might include the results of pulse oximetry testing, vital signs, or a patient behavior that is observed. Any assessment finding that the nurse detects through use of visual, auditory, olfactory, and tactile senses would be noted under data. These entries represent the data collection and assessment stage of the nursing process.
B The second part of DAR charting is action, which is where the nurse charts interventions. Examples might include teaching, repositioning, administering prn medications, changing a dressing, or notifying the physician of an abnormal lab result. These entries reflect the planning and implementing stages of the nursing process. Chapter Objective: Contrast charting by exception and focus charting.
C The third part of DAR charting is response, which refers to the patient’s response to the interventions and reflects the evaluation phase of the nursing process.
D Assessment is not a part of the acronym DAR.

PTS: 1 REF: Chapter: 5 | Page: 99 OBJ: Chapter Objective: 5-8

KEY:Content Area: DAR Charting | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

MULTIPLE RESPONSE

1.ANS:A, B, D, E, F

Feedback: Written documentation communicates pertinent data that all health care team members need to provide continuity of care; serves as a record of accountability for quality assurance, accreditation, and reimbursement purposes; provides a permanent record of medical diagnoses, nursing diagnoses, plan of care, care provided, and the patient’s response to that care; and serves as a legal record for both the patient and the health care provider. Chapter Objective: Summarize 12 guidelines for documentation.

PTS: 1 REF: Chapter: 5 | Page: 80 OBJ: Chapter Objective: 5-4

KEY: Content Area: Documentation| Integrated Process: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

2.ANS:A, C, D, E, F

Feedback: To be accredited by The Joint Commission, a facility must practice in a manner that meets The Joint Commission’s standards. This is determined by a team of reviewers who visit the facility to assess its policies, procedures, and actual performance, and who ensure that the standards are met. The Joint Commission sets the standards by which the quality of health care is measured both nationally and internationally. The Joint Commission seeks to improve safety and quality of care that health care organizations provide to the public. Chapter Objective: Explain four purposes of written documentation.

PTS: 1 REF: Chapter: 5 | Page: 81 OBJ: Chapter Objective: 5-2

KEY: Content Area: The Joint Commission | Integrated Process: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

3.ANS:A, C, D, E, F

Feedback: 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. HIPPA also gives the patient the right to amend his or her own health information and specify who can obtain this information. HIPAA also requires hospitals to disclose the way in which the patient’s health data will be used. Chapter Objective: Discuss confidentiality of patient records.

PTS: 1 REF: Chapter: 5 | Page: 82 OBJ: Chapter Objective: 5-3

KEY: Content Area: Medical Record | Integrated Process: Teaching and Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

4.ANS:C, D, E, F

Feedback: Incident reports, also known as variance reports, are used to document out-of-the-ordinary things that happen in a facility. The incident or occurrence may or may not actually involve a patient and is not part of the patient’s medical record. Occurrences that should be documented on an incident or variance report form include the following: medication error, patient injury; visitor injury; employee injury; condition constituting a safety hazard, such as unsafe staffing situation or failure to repair reported broken or damaged equipment; failure of appropriate health care provider response to an emergency; failure to perform ordered care; loss of a patient’s personal belongings, prosthetic or assistive devices, home medications, or secured valuables; lack of availability of vital patient care supplies or equipment. Chapter Objective: Explain four purposes of written documentation.

PTS: 1 REF: Chapter: 5 | Page: 83 OBJ: Chapter Objective: 5-2

KEY: Content Area: Incident Report | Integrated Process: Teaching and Learning | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

5.ANS:A, B, C, D

Feedback: The problem-oriented medical record will have four primary sections: database, problem list, plan of care, and progress notes. Incident reports (also known as variance reports) are not part of the patient’s medical record. Chapter Objective: Compare source-oriented and problem-oriented documentation systems.

PTS: 1 REF: Chapter: 5 | Page: 95 OBJ: Chapter Objective: 5-5

KEY:Content Area: Problem-oriented medical record | Integrated Process: Documentation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

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