NU 311 EXAM 2 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS GRADED A++ LATEST
UPDATE
what NOT to do while recording documentations and informatics
do NOT: erase, apply correction fluid or scratch out errors, write retaliatory or critical
comments about patient or care by other HCPs, try to add additional information to a
previously made entry, rush to complete charting, speculate or guess while making
entries, leave blank spaces, use a pencil or felt tip pen, record errors, wait until the end
of shift to record important changes, leave screen unattended if logged on, share
password
what TO do while recording documentations and informatics
DO: draw a single line through errors, write the word "error" above it, sign initials next to
it, enter only objective descriptions, use quotes for patient comments, add new
information for an old entry by writing the date and time of the new entry next to it, make
sure information is accurate, record all facts, chart consecutively line by line leaving no
spaces, use blue or black ink pen, record any clarifications made, chart only for
yourself, use complete and concise descriptions of care, begin each entry with time and
end with your signature
What does nursing documentation do?
,ensures continuity of care
provides legal evidence
records evaluation of patient outcomes
which of the following examples illustrates the benefit of collecting data using
computerized systems?
a. a hospital found that the highest readmission rate was seen in patients with
congestive heart failure
b. The computer system lacks appropriate backup personnel; therefore the nurse
is assigned this task.
c. The federal government has penalized the hospital for lack of compliance with
electronic medical records.
d. Data for elderly patients were cleared from the system to make more storage
space for newborn delivery rates.
a. a hospital found that they highest readmission rate was seen in patients with
congestive heart failure
SOAP documentation
Subjective
Objective
Assessment/Analysis
Plan
SBAR documentation
, Situation
Background
Assessment
Recommendation
DART chart
Data
Action
Response
Teaching
Additional "R" on the DART sheet
Repeat: have the patient repeat what they have learned
each DART note covers ___ problem(s)
one
Notes must reflect the nursing process, so they must have which aspects?
a. assessment of data
b. changes in patient's condition
c. nursing interventions
d. evaluation
e. all of the above
e. all of the above: assessment of data, changes in patient's condition, nursing
interventions, and evaluation
what does HIPAA stand for?
COMPLETE SOLUTIONS GRADED A++ LATEST
UPDATE
what NOT to do while recording documentations and informatics
do NOT: erase, apply correction fluid or scratch out errors, write retaliatory or critical
comments about patient or care by other HCPs, try to add additional information to a
previously made entry, rush to complete charting, speculate or guess while making
entries, leave blank spaces, use a pencil or felt tip pen, record errors, wait until the end
of shift to record important changes, leave screen unattended if logged on, share
password
what TO do while recording documentations and informatics
DO: draw a single line through errors, write the word "error" above it, sign initials next to
it, enter only objective descriptions, use quotes for patient comments, add new
information for an old entry by writing the date and time of the new entry next to it, make
sure information is accurate, record all facts, chart consecutively line by line leaving no
spaces, use blue or black ink pen, record any clarifications made, chart only for
yourself, use complete and concise descriptions of care, begin each entry with time and
end with your signature
What does nursing documentation do?
,ensures continuity of care
provides legal evidence
records evaluation of patient outcomes
which of the following examples illustrates the benefit of collecting data using
computerized systems?
a. a hospital found that the highest readmission rate was seen in patients with
congestive heart failure
b. The computer system lacks appropriate backup personnel; therefore the nurse
is assigned this task.
c. The federal government has penalized the hospital for lack of compliance with
electronic medical records.
d. Data for elderly patients were cleared from the system to make more storage
space for newborn delivery rates.
a. a hospital found that they highest readmission rate was seen in patients with
congestive heart failure
SOAP documentation
Subjective
Objective
Assessment/Analysis
Plan
SBAR documentation
, Situation
Background
Assessment
Recommendation
DART chart
Data
Action
Response
Teaching
Additional "R" on the DART sheet
Repeat: have the patient repeat what they have learned
each DART note covers ___ problem(s)
one
Notes must reflect the nursing process, so they must have which aspects?
a. assessment of data
b. changes in patient's condition
c. nursing interventions
d. evaluation
e. all of the above
e. all of the above: assessment of data, changes in patient's condition, nursing
interventions, and evaluation
what does HIPAA stand for?
