CHAPTER 10: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 10: Documentation, Electronic Health Records, and Reporting Multiple Choice Questions 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. Answer: A Explanation: Accurate documentation ensures hospitals are reimbursed under diagnostic-related groups (DRGs) and serves as legal evidence. It includes electronic records, faxes, and emails, not just handwritten notes. Why Other Options Are Wrong: B is incorrect because documentation can be paper or electronic. C is false as emails/faxes are valid forms. D is inaccurate since electronic records are legally admissible. 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. Answer: D Explanation: The ANA’s model for quality documentation aligns with the nursing process, emphasizing accuracy, relevance, and timeliness. Why Other Options Are Wrong: A is false as standards are set by individual organizations. B violates privacy laws. C contradicts CMS guidelines requiring diagnosis documentation. 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. C. It is not used to determine reimbursement claims. D. It can be used as a tool for biomedical research and provide education. Answer: D Explanation: Medical records support research, education, and statistical analysis while ensuring continuity of care and legal compliance. Why Other Options Are Wrong: A is incorrect as records are legal documents. B and C are false because records assess quality and justify reimbursement. 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. Answer: A Explanation: Paper degrades over time, is easily damaged, and poses storage and retrieval challenges. Why Other Options Are Wrong: B is false due to limited accessibility. C contradicts storage difficulties. D is incorrect as paper degrades. 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. Answer: D Explanation: Black ink ensures legibility for copying/scanning, and entries include credentials without blank spaces to prevent tampering. Why Other Options Are Wrong: A is incorrect as signatures are required. B omits required credentials. C risks unauthorized additions. 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. Answer: C Explanation: EHRs provide longitudinal health data across multiple care settings, unlike EMRs (single episodes) or CPOE (order entry). Why Other Options Are Wrong: A lacks historical breadth. B is for orders, not history. D may be incomplete. 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. Answer: A Explanation: EHRs enhance care quality, reduce errors, and improve outcomes through better monitoring and guideline adherence. Why Other Options Are Wrong: B is false as data can be entered via voice or pens. C contradicts error reduction evidence. D is incorrect as EHRs reduce physical storage needs. 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. Answer: C Explanation: Password confidentiality is critical to prevent unauthorized access and protect patient data. Why Other Options Are Wrong: A violates security protocols. B is false as systems track access. D is incorrect as EHRs can fail. 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. Answer: A Explanation: Documentation must be factual, nonjudgmental, and include patient-reported subjective data. Why Other Options Are Wrong: B is unprofessional. C delays timely entries. D creates legal risks with conflicting data. 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. Answer: A Explanation: Documentation follows the nursing process steps: assessment, diagnosis, planning, implementation, and evaluation. Why Other Options Are Wrong: B, C, and D are tools used within the nursing process but do not guide it entirely. 11. What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation? A. They are chronologic. B. They are examples of problem-oriented charting. C. They are narrative charting. D. They are forms of "charting by exception." Answer: B Explanation: These formats organize notes by patient problems, interventions, and evaluations, unlike narrative or exception-based charting. Why Other Options Are Wrong: A describes narrative charting. C is incorrect as they are structured. D refers to CBE. 12. The nursing instructor teaching students about charting explains that this type of charting records only abnormal or significant data? A. PIE. B. SOAP. C. Narrative. D. Charting by exception. Answer: D Explanation: Charting by exception (CBE) focuses on deviations from norms, omitting routine findings. Why Other Options Are Wrong: A, B, and C document all data, not just abnormalities. 13. Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document? A. Flow sheet. B. Kardex. C. MAR. D. Admission summary. Answer: C Explanation: The Medication Administration Record (MAR) lists ordered medications, doses, and times for verification. Why Other Options Are Wrong: A tracks routine care. B holds generic patient info. D includes history but not current orders. 14. The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. What is the best central location for the nurse to obtain this information? A. Admission summary. B. Discharge summary. C. Flow sheet. D. Kardex. Answer: A Explanation: Admission summaries include patient history, home medications, and initial assessments. Why Other Options Are Wrong: B details discharge plans. C tracks routine data. D may lack comprehensive history. 15. What fact is the nurse aware of when charting using paper nursing notes? A. Use red ink so the nursing entries stand out. B. When mistakes are made in documentation, the nurse should white out the entry. C. Only one nurse should document on a sheet so that it can be removed in case of error. D. The medical record, in any format, is the most reliable source of information in a legal action. Answer: D Explanation: Medical records are primary legal evidence, requiring accuracy and integrity without alteration. Why Other Options Are Wrong: A is incorrect as black/blue ink is standard. B and C violate legal documentation standards. 16. What fact is the nurse aware of when charting using electronic documentation? A. Errors can be corrected and totally removed from the record in the screen view. B. Log-on access to the electronic record identifies the person charting. C. Each entry requires the nurse to sign her/his name and credentials. D. Documenting significant changes in the electronic record ends the nurse's responsibility. Answer: B Explanation: Electronic systems track user logins, ensuring accountability for entries. Why Other Options Are Wrong: A is false as corrections remain in audit trails. C is incorrect as credentials are auto-logged. D is untrue as providers must be notified of critical changes. 17. What action should the nurse take to correct an error in paper charting? A. Remove the sheet with the error and replace it with a new sheet with the correct entry. B. Scribble out the error and rewrite the entry correctly. C. Draw a single line through the error, write "error" above or after the entry, along with the nurse's initials. D. Leave the entry as is and tell the charge nurse. Answer: C Explanation: Errors must be clearly marked, corrected, and initialed to maintain transparency without obliterating original entries. Why Other Options Are Wrong: A and B are unethical. D neglects documentation standards. 18. If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed? A. The order must be taken by an RN or LPN. B. The order must be repeated verbatim to confirm accuracy. C. The order is documented as a written order. D. The order does not need further verification by the provider. Answer: B Explanation: Verbal orders require RN verification by repetition and documentation as "verbal/phone orders" pending provider co-signature. Why Other Options Are Wrong: A is incorrect as LPNs cannot accept verbal orders. C and D violate protocol requiring co-signature. 19. The nurse identifies which statement to be accurate regarding the process of making a change-of-shift report (handoff)? A. Handoff is an uncommon occurrence of little importance. B. Handoff occurs only at change of shift and only to oncoming nurses. C. Handoff can lead to patient death if done incorrectly. D. Handoff does not allow for collaboration or problem solving. Answer: C Explanation: Ineffective handoffs may cause treatment errors, prolonged stays, or fatalities, making accuracy critical. Why Other Options Are Wrong: A is false as handoffs are frequent and vital. B is incorrect as handoffs involve multiple team members. D contradicts the collaborative nature of handoffs. 20. When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task? A. Complete an incident report as a risk management document. B. Complete an incident report and add it to the medical record. C. Document that an incident report was completed in the medical record. D. Say nothing about the incident in the medical record. Answer: A Explanation: Incident reports are internal risk management tools; details of the event are documented separately in the medical record. Why Other Options Are Wrong: B and C are incorrect as reports are not part of the medical record. D neglects required documentation. MULTIPLE RESPONSE QUESTIONS 1. The nurse identifies which components to be expected nursing documentation? (Select all that apply.) A. Nursing assessment. B. The care plan. C. Critique of the physician's care. D. Interventions. E. Patient responses to care. Answer: A, B, D, E Explanation: Documentation includes assessments, care plans, interventions, and patient outcomes, but not critiques of other providers. Why Other Options Are Wrong: C is unprofessional and irrelevant to nursing documentation. 2. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. The nurse identifies which abbreviations to be unacceptable? (Select all that apply.) A. prn. B. QD. C. qod. D. 0.X mg. E. X mg. Answer: B, C Explanation: QD and qod are error-prone; "daily" or "every other day" should be written instead. Why Other Options Are Wrong: A is acceptable. D and E follow safe notation guidelines. 3. The nurse understands the use of standardized language in care planning is beneficial for what reasons? (Select all that apply.) A. Standardized language provides consistency. B. Standardized language improves communication among nurses. C. Standardized language increases the visibility of nursing interventions. D. Standardized language enhances data collection. E. Standardized language supports adherence to care standards. Answer: A, B, C, D, E Explanation: Standardized terminology (e.g., NANDA-I, NIC, NOC) ensures clarity, consistency, and measurable outcomes across care settings. Why Other Options Are Wrong: All options are correct benefits of standardized language. 4. When charting is done using the DAR charting format, the nurse documents which components? (Select all that apply.) A. The patient problems. B. Subjective data. C. Any actions initiated. D. Objective data. E. The patient's response to interventions. Answer: A, C, E Explanation: DAR focuses on Data (problems), Action (interventions), and Response (outcomes). Why Other Options Are Wrong: B and D are part of SOAP, not DAR. 5. The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances? (Select all that apply.) A. To provide treatment for the patient. B. To determine billing and payment issues. C. To enhance health care operations related to the patient. D. In public areas such as the cafeteria or elevator. E. Over the telephone with any family member. Answer: A, B, C Explanation: HIPAA permits sharing for treatment, payment, and operations but requires privacy in public or with unauthorized individuals. Why Other Options Are Wrong: D and E violate HIPAA privacy rules. 6. The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report? (Select all that apply.) A. Patient is an 84-year-old female with a history of hypertension: S. B. Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S. C. Patient is hemorrhaging with four saturated dressings in an hour: A. D. The patient took an overdose of antidepressants three days ago: B. E. By policy, the patient needs transferred to the ICU; please come write the orders: R. Answer: B, C, D, E Explanation: SBAR organizes data as Situation (current issue), Background (context), Assessment (problem identification), and Recommendation (action). Why Other Options Are Wrong: A is Background, not Situation.