RNRS 116 DOCUMENTATION AND REPORTING (PEARSON)
EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
A healthcare organization uses the case management method of documentation.
Which information should the nurse document if a patient goal is not met?
No further documentation
Data to support a variance
Data, action, and response
Problem, action, evaluation
Data to support a variance
The nurse informs the supervisor about a patient's primary diagnosis written in the chart
without being accompanied by a diagnosis-related group (DRG) code.
Which statement best describes the rationale for the nurse's action?
The DRG shows that two doctors have agreed upon a diagnosis.
Without a DRG, the nurse cannot write nursing interventions based on the chart data.
The DRG, or doctor reimbursement group code, is required for insurance but not
Medicare reimbursement.
, The DRG must be present for each diagnosis for the hospital or agency to be
reimbursed.
The DRG must be present for each diagnosis for the hospital or agency to be
reimbursed.
The Joint Commission has implemented the new Handoff Communications Targeted
Solutions Tool (TST).
Which statement should the nurse use to best describe the use of the TST to other
colleagues?
Assist agencies in the passing of patient-related information among caregivers
Help reduce active shooter incidents in hospitals
Help prevent medical errors
Make sure hospitals reach budget targets each month
Assist agencies in the passing of patient-related information among caregivers
Which statement represents a disadvantage of the source-oriented record
documentation system?
Information about a particular patient problem is scattered throughout the chart.
Care providers from each discipline have difficulty locating the discipline-specific forms
on which to record data.
It is difficult to trace the information specific to each provider's discipline.
Caregivers differ in their ability to use the required charting format.
Information about a particular patient problem is scattered throughout the chart.
EXAM QUESTIONS AND ANSWERS WITH COMPLETE
SOLUTIONS VERIFIED
A healthcare organization uses the case management method of documentation.
Which information should the nurse document if a patient goal is not met?
No further documentation
Data to support a variance
Data, action, and response
Problem, action, evaluation
Data to support a variance
The nurse informs the supervisor about a patient's primary diagnosis written in the chart
without being accompanied by a diagnosis-related group (DRG) code.
Which statement best describes the rationale for the nurse's action?
The DRG shows that two doctors have agreed upon a diagnosis.
Without a DRG, the nurse cannot write nursing interventions based on the chart data.
The DRG, or doctor reimbursement group code, is required for insurance but not
Medicare reimbursement.
, The DRG must be present for each diagnosis for the hospital or agency to be
reimbursed.
The DRG must be present for each diagnosis for the hospital or agency to be
reimbursed.
The Joint Commission has implemented the new Handoff Communications Targeted
Solutions Tool (TST).
Which statement should the nurse use to best describe the use of the TST to other
colleagues?
Assist agencies in the passing of patient-related information among caregivers
Help reduce active shooter incidents in hospitals
Help prevent medical errors
Make sure hospitals reach budget targets each month
Assist agencies in the passing of patient-related information among caregivers
Which statement represents a disadvantage of the source-oriented record
documentation system?
Information about a particular patient problem is scattered throughout the chart.
Care providers from each discipline have difficulty locating the discipline-specific forms
on which to record data.
It is difficult to trace the information specific to each provider's discipline.
Caregivers differ in their ability to use the required charting format.
Information about a particular patient problem is scattered throughout the chart.
