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Chapter 10: Documentation, Electronic Health Records, and Reporting
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse understands the need for accurate documentation due to which fact?
a. Accurate documentation is needed for proper reimbursement.
b. Accurate documentation must be electronically generated.
c. Accurate documentation does not include e-mails or faxes.
d. Accurate documentation is only accepted in court if written by hand.
ANS: A
Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-
related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care
documentation is any written or electronically generated information about a patient that
describes the patient, the patient’s health, and the care and services provided, including the
dates of care. These records may be paper or electronic documents, such as electronic medical
records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered
legal documentation and may be used in court.
DIF: Remembering OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
2. The nurse identifies which statement to be true regarding nursing documentation?
a. Standards for documentation are established by a national commission.
b. Medical records should be accessible to everyone.
c. Documentation should not include the patient’s diagnosis.
d. High-quality nursing documentation reflects the nursing process.
ANS: D
The ANA’s model for high-quality nursing documentation reflects the nursing process and
includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and
retrievability. Standards for documentation are established by each health care organization’s
policies and procedures. They should be in agreement with The Joint Commission’s standards
and elements of performance, including having a medical record for each patient that is
accessed only by authorized personnel. General principles of medical record documentation
from the Centers for Medicare and Medicaid Services (2017) include the need for
completeness and legibility; the reasons for each patient encounter, including assessments and
diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis and
treatment.
DIF: Understanding OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
3. The nurse identifies which true statement regarding the medical record?
a. It serves as a major communication tool but is not a legal document.
b. It cannot be used to assess quality of care issues.
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c. It is not used to determine reimbursement claims.
d. It can be used as a tool for biomedical research and provide education.
ANS: D
The medical record promotes continuity of care and ensures that patients receive appropriate
health care services. The record can be used to assess quality-of-care measures, determine the
medical necessity of health care services, support reimbursement claims, and protect health
care providers, patients, and others in legal matters. It is a clinical data archive. The medical
record serves as a tool for biomedical research and provider education, collection of statistical
data for government and other agencies, maintenance of compliance with external regulatory
bodies, and establishment of policies and regulations for standards of care. The record serves
as the major communication tool between staff members and as a single data access point for
everyone involved in the patient’s care. It is a legal document that must meet guidelines for
completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to
assess quality-of-care measures, determine the medical necessity of health care services,
support reimbursement claims, and protect health care providers, patients, and others in legal
matters.
DIF: Understanding OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
4. The nurse knows that paper records are being replaced by other forms of record keeping for
what reason?
a.Paper is fragile and susceptible to damage.
b.Paper records are always available to multiple people at a time.
c.Paper records can be stored without difficulty and are easily retrievable.
d.Paper records are permanent and last indefinitely.
ANS: A
Paper records have several potential problems. Paper is fragile, susceptible to damage, and can
degrade over time. It may be difficult to locate a particular chart because it is being used by
someone else, it is in a different department, or it is misfiled. Storage and control of paper
records can be a major problem.
DIF: Evaluating OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
5. When the nurse is charting in the paper medical record, what action does the nurse carry out?
a. Print his/her name since signatures are often not readable.
b. Omit nursing credentials since only the nurses chart
c. Skip a line between entries so that it looks neat.
d. Use black ink unless the facility allows a different color.
ANS: D
Entries into paper medical records are traditionally made with black ink to enable copying or
scanning, unless a facility requires or allows a different color. The date, time, and signature,
with credentials of the person writing the entry, are included in the entry. No blank spaces are
left between entries because they could allow someone to add a note out of sequence.
DIF: Remembering OBJ: 10.3 TOP: Implementation
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MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
6. The nurse is admitting a patient who has had several previous admissions. To obtain a
knowledge base about the patient’s medical history, the nurse would access which document?
a. Electronic medical record (EMR)
b. The computerized provider order entry (CPOE)
c. Electronic health record (EHR)
d. Primary provider’s office notes
ANS: C
The EHR is a longitudinal record of health that includes the information from inpatient and
outpatient episodes of health care from one or more care settings. The EMR is a record of one
episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows
clinicians to enter orders in a computer that are sent directly to the appropriate department. It
does not provide historical data. The primary provider’s office notes may not include all the
patient’s information if the patient has other providers.
DIF: Applying OBJ: 10.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
7. The nurse understands which statement about the use of electronic health records is true?
a. They improve patient health status.
b. They require a keyboard to enter data.
c. They have not reduced medication errors.
d. They require increased storage space.
ANS: A
Adoption of an EHR system produces major cost savings through gains in productivity and
error reduction, which ultimately improves patient health status. The most common benefits of
electronic records are increased delivery of guideline-based care, better monitoring, reduced
medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow
simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and
increase portability in environments using wireless systems and hand-held devices. Although
data are often entered by keyboard, they can also be entered by means of dictated voice
recordings, light pens, or handwriting and pattern recognition systems.
DIF: Remembering OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
8. The nurse is caring for patients on a unit that uses electronic health records (EHRs). What
action by the nurse protects personal health information?
a. The nurse should allow only nurses that he/she knows and trusts to use his/her
verification code.
b. The nurse should not worry about mistakes since the information cannot be
tracked.
c. The nurse should never share any password with anyone.
d. The nurse should be aware that the EHR is sophisticated and immune to failure.
ANS: C
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Access to an EHR is controlled through assignment of individual passwords and verification
codes that identify people who have the right to enter the record. Passwords and verification
codes should never be shared with anyone. Health care information systems have the ability to
track who uses the system and which records are accessed. These organizational tools
contribute to the protection of personal health information. Disadvantages of use of computers
for documentation include computer and software failure and problems if there is a power
outage.
DIF: Applying OBJ: 10.4 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
9. The nurse recognizes which statement to be accurate regarding what should be documented?
a. Document facts and subjective data from the patient.
b. Document how he/she feels about the care being provided.
c. Document in a “block” fashion once per shift.
d. Double document as often as possible in order to not miss anything.
ANS: A
Nursing documentation is an important part of effective communication among nurses and
with other health care providers. Documentation should be factual and nonjudgmental, with
proper spelling and grammar. Subjective data from the patient should be included. Events
should be reported in the order they happened, and documentation should occur as soon as
possible after assessment, interventions, condition changes, or evaluation. Each entry includes
the date, time, and signature with credentials of the person documenting. Double
documentation of data should be avoided because legal issues can arise as a result of
conflicting data.
DIF: Remembering OBJ: 10.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
10. The nurse recognizes that nursing documentation is guided by what process?
a. The nursing process
b. NANDA-I, nursing diagnoses
c. Nursing interventions classification
d. Nursing Outcomes Classification
ANS: A
Nursing documentation is guided by the five steps of the nursing process: assessment,
diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such
as the North American Nursing Diagnosis Association–International (NANDA-I) Nursing
Diagnoses, nursing interventions classification (NIC), and Nursing Outcomes Classification
(NOC) may be used in the documentation process.
DIF: Remembering OBJ: 10.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
11. What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation?
a. They are chronologic.
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Chapter 10: Documentation, Electronic Health Records, and Reporting
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse understands the need for accurate documentation due to which fact?
a. Accurate documentation is needed for proper reimbursement.
b. Accurate documentation must be electronically generated.
c. Accurate documentation does not include e-mails or faxes.
d. Accurate documentation is only accepted in court if written by hand.
ANS: A
Accurate documentation is necessary for hospitals to be reimbursed according to diagnostic-
related groups (DRGs). DRGs are a system used to classify hospital admissions. Health care
documentation is any written or electronically generated information about a patient that
describes the patient, the patient’s health, and the care and services provided, including the
dates of care. These records may be paper or electronic documents, such as electronic medical
records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered
legal documentation and may be used in court.
DIF: Remembering OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
2. The nurse identifies which statement to be true regarding nursing documentation?
a. Standards for documentation are established by a national commission.
b. Medical records should be accessible to everyone.
c. Documentation should not include the patient’s diagnosis.
d. High-quality nursing documentation reflects the nursing process.
ANS: D
The ANA’s model for high-quality nursing documentation reflects the nursing process and
includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and
retrievability. Standards for documentation are established by each health care organization’s
policies and procedures. They should be in agreement with The Joint Commission’s standards
and elements of performance, including having a medical record for each patient that is
accessed only by authorized personnel. General principles of medical record documentation
from the Centers for Medicare and Medicaid Services (2017) include the need for
completeness and legibility; the reasons for each patient encounter, including assessments and
diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis and
treatment.
DIF: Understanding OBJ: 10.1 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
3. The nurse identifies which true statement regarding the medical record?
a. It serves as a major communication tool but is not a legal document.
b. It cannot be used to assess quality of care issues.
Downloaded by: SuperA |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
c. It is not used to determine reimbursement claims.
d. It can be used as a tool for biomedical research and provide education.
ANS: D
The medical record promotes continuity of care and ensures that patients receive appropriate
health care services. The record can be used to assess quality-of-care measures, determine the
medical necessity of health care services, support reimbursement claims, and protect health
care providers, patients, and others in legal matters. It is a clinical data archive. The medical
record serves as a tool for biomedical research and provider education, collection of statistical
data for government and other agencies, maintenance of compliance with external regulatory
bodies, and establishment of policies and regulations for standards of care. The record serves
as the major communication tool between staff members and as a single data access point for
everyone involved in the patient’s care. It is a legal document that must meet guidelines for
completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to
assess quality-of-care measures, determine the medical necessity of health care services,
support reimbursement claims, and protect health care providers, patients, and others in legal
matters.
DIF: Understanding OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
4. The nurse knows that paper records are being replaced by other forms of record keeping for
what reason?
a.Paper is fragile and susceptible to damage.
b.Paper records are always available to multiple people at a time.
c.Paper records can be stored without difficulty and are easily retrievable.
d.Paper records are permanent and last indefinitely.
ANS: A
Paper records have several potential problems. Paper is fragile, susceptible to damage, and can
degrade over time. It may be difficult to locate a particular chart because it is being used by
someone else, it is in a different department, or it is misfiled. Storage and control of paper
records can be a major problem.
DIF: Evaluating OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
5. When the nurse is charting in the paper medical record, what action does the nurse carry out?
a. Print his/her name since signatures are often not readable.
b. Omit nursing credentials since only the nurses chart
c. Skip a line between entries so that it looks neat.
d. Use black ink unless the facility allows a different color.
ANS: D
Entries into paper medical records are traditionally made with black ink to enable copying or
scanning, unless a facility requires or allows a different color. The date, time, and signature,
with credentials of the person writing the entry, are included in the entry. No blank spaces are
left between entries because they could allow someone to add a note out of sequence.
DIF: Remembering OBJ: 10.3 TOP: Implementation
Downloaded by: SuperA |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
6. The nurse is admitting a patient who has had several previous admissions. To obtain a
knowledge base about the patient’s medical history, the nurse would access which document?
a. Electronic medical record (EMR)
b. The computerized provider order entry (CPOE)
c. Electronic health record (EHR)
d. Primary provider’s office notes
ANS: C
The EHR is a longitudinal record of health that includes the information from inpatient and
outpatient episodes of health care from one or more care settings. The EMR is a record of one
episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows
clinicians to enter orders in a computer that are sent directly to the appropriate department. It
does not provide historical data. The primary provider’s office notes may not include all the
patient’s information if the patient has other providers.
DIF: Applying OBJ: 10.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
7. The nurse understands which statement about the use of electronic health records is true?
a. They improve patient health status.
b. They require a keyboard to enter data.
c. They have not reduced medication errors.
d. They require increased storage space.
ANS: A
Adoption of an EHR system produces major cost savings through gains in productivity and
error reduction, which ultimately improves patient health status. The most common benefits of
electronic records are increased delivery of guideline-based care, better monitoring, reduced
medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow
simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and
increase portability in environments using wireless systems and hand-held devices. Although
data are often entered by keyboard, they can also be entered by means of dictated voice
recordings, light pens, or handwriting and pattern recognition systems.
DIF: Remembering OBJ: 10.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
8. The nurse is caring for patients on a unit that uses electronic health records (EHRs). What
action by the nurse protects personal health information?
a. The nurse should allow only nurses that he/she knows and trusts to use his/her
verification code.
b. The nurse should not worry about mistakes since the information cannot be
tracked.
c. The nurse should never share any password with anyone.
d. The nurse should be aware that the EHR is sophisticated and immune to failure.
ANS: C
Downloaded by: SuperA |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
Access to an EHR is controlled through assignment of individual passwords and verification
codes that identify people who have the right to enter the record. Passwords and verification
codes should never be shared with anyone. Health care information systems have the ability to
track who uses the system and which records are accessed. These organizational tools
contribute to the protection of personal health information. Disadvantages of use of computers
for documentation include computer and software failure and problems if there is a power
outage.
DIF: Applying OBJ: 10.4 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
9. The nurse recognizes which statement to be accurate regarding what should be documented?
a. Document facts and subjective data from the patient.
b. Document how he/she feels about the care being provided.
c. Document in a “block” fashion once per shift.
d. Double document as often as possible in order to not miss anything.
ANS: A
Nursing documentation is an important part of effective communication among nurses and
with other health care providers. Documentation should be factual and nonjudgmental, with
proper spelling and grammar. Subjective data from the patient should be included. Events
should be reported in the order they happened, and documentation should occur as soon as
possible after assessment, interventions, condition changes, or evaluation. Each entry includes
the date, time, and signature with credentials of the person documenting. Double
documentation of data should be avoided because legal issues can arise as a result of
conflicting data.
DIF: Remembering OBJ: 10.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
10. The nurse recognizes that nursing documentation is guided by what process?
a. The nursing process
b. NANDA-I, nursing diagnoses
c. Nursing interventions classification
d. Nursing Outcomes Classification
ANS: A
Nursing documentation is guided by the five steps of the nursing process: assessment,
diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such
as the North American Nursing Diagnosis Association–International (NANDA-I) Nursing
Diagnoses, nursing interventions classification (NIC), and Nursing Outcomes Classification
(NOC) may be used in the documentation process.
DIF: Remembering OBJ: 10.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Communication
11. What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation?
a. They are chronologic.
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