NF2 Exam #5 Chapter 5 questions well
answered to pass rated A+
Documentation - correct answer ✔✔the act of charting or making written notation of all the things that
are pertinent to each patient for whom a nurse provides care
Electronic Health Record (EHR) - correct answer ✔✔A computerized database that typically includes
present and past medical and surgical information, laboratory, radiographic and drug information about
a patient; most also contain billing and insurance information as well.
Charting by exception - correct answer ✔✔Notes written by health-care providers that focus only on
abnormal findings; normal findings are not charted, and checklists are used for routine care
Works best with EHR
confidentiality - correct answer ✔✔the maintenance of privacy by not sharing with third party privileged
or entrusted information
purposes of documentation - correct answer ✔✔1. provide Continuity of care
2.provide Permanent record
3. a record of Accountability for quality assurance
4. a Legal Record for both the patient and the health-care provider
***CPAL***
to be accredited by The Joint Commission: - correct answer ✔✔a facility must practice in a manner that
meets The Joint Commission's standards. This is determined by a team of reviews who visit the facility to
assess its policies, procedures, and actual preformance and ensure that the standards are met.
Safety: From a legal standpoint, it is best to assume that if it wasn't charted, it wasn't done. - correct
answer ✔✔.
, The phrase "Not charted, not done" - correct answer ✔✔is interpreted to mean that if something is not
documented, then it was not done or did not occur
lawsuits often are not filed until: - correct answer ✔✔years after the precipitating event, possibly long
after the patient or event has been forgotten
HIPPA - correct answer ✔✔-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
-ensures the patient's right not only to view and copy their own medical record but also to amend their
own health information
-requires hospitals and medical sites to disclose to each patient, in writing, the way the patient's health
data will be used and to ask the patient to specify who can obtain the patient's personal health data.
Safety: Never allow anyone to access the chart until you have verified the facility's policy and ensured
that the patient has granted consent in writing. - correct answer ✔✔.
Safety: Remember that you cannot confirm that an individual is a patient in your facility without specific
permission from the patient. - correct answer ✔✔.
Safety: Take care to avoid leaving patient care notes, laboratory results, medication administration
records (MARS), and patient charts lying open and accessible to other facility employees and the public. -
correct answer ✔✔.
Safety: Any handwritten notes or copies of confidential patient information should be shredded after
their purpose has been fulfilled. - correct answer ✔✔.
Safety: Just before you fax the medical record, telephone the intended recipient to inform him or her of
the impending confidential fax. - correct answer ✔✔.
report form will need specific areas to document: - correct answer ✔✔-room number; patient name,
age, weight, sex; and attending physician
-Date of admission and diagnoses
-Frequency of vital signs and activity orders
answered to pass rated A+
Documentation - correct answer ✔✔the act of charting or making written notation of all the things that
are pertinent to each patient for whom a nurse provides care
Electronic Health Record (EHR) - correct answer ✔✔A computerized database that typically includes
present and past medical and surgical information, laboratory, radiographic and drug information about
a patient; most also contain billing and insurance information as well.
Charting by exception - correct answer ✔✔Notes written by health-care providers that focus only on
abnormal findings; normal findings are not charted, and checklists are used for routine care
Works best with EHR
confidentiality - correct answer ✔✔the maintenance of privacy by not sharing with third party privileged
or entrusted information
purposes of documentation - correct answer ✔✔1. provide Continuity of care
2.provide Permanent record
3. a record of Accountability for quality assurance
4. a Legal Record for both the patient and the health-care provider
***CPAL***
to be accredited by The Joint Commission: - correct answer ✔✔a facility must practice in a manner that
meets The Joint Commission's standards. This is determined by a team of reviews who visit the facility to
assess its policies, procedures, and actual preformance and ensure that the standards are met.
Safety: From a legal standpoint, it is best to assume that if it wasn't charted, it wasn't done. - correct
answer ✔✔.
, The phrase "Not charted, not done" - correct answer ✔✔is interpreted to mean that if something is not
documented, then it was not done or did not occur
lawsuits often are not filed until: - correct answer ✔✔years after the precipitating event, possibly long
after the patient or event has been forgotten
HIPPA - correct answer ✔✔-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
-ensures the patient's right not only to view and copy their own medical record but also to amend their
own health information
-requires hospitals and medical sites to disclose to each patient, in writing, the way the patient's health
data will be used and to ask the patient to specify who can obtain the patient's personal health data.
Safety: Never allow anyone to access the chart until you have verified the facility's policy and ensured
that the patient has granted consent in writing. - correct answer ✔✔.
Safety: Remember that you cannot confirm that an individual is a patient in your facility without specific
permission from the patient. - correct answer ✔✔.
Safety: Take care to avoid leaving patient care notes, laboratory results, medication administration
records (MARS), and patient charts lying open and accessible to other facility employees and the public. -
correct answer ✔✔.
Safety: Any handwritten notes or copies of confidential patient information should be shredded after
their purpose has been fulfilled. - correct answer ✔✔.
Safety: Just before you fax the medical record, telephone the intended recipient to inform him or her of
the impending confidential fax. - correct answer ✔✔.
report form will need specific areas to document: - correct answer ✔✔-room number; patient name,
age, weight, sex; and attending physician
-Date of admission and diagnoses
-Frequency of vital signs and activity orders
