C HAPTER 03: D OCUMENTATION
Cooper: Foundation of Nursing, 9th Edition
MULTIPLE CHOICE
1. What is the process used to appraise the practice of an individual nurse
known as?
a. Qualit y assurance
b. Incident reporting
c. OBRA
d. Peer review
ANS: D
Peer review is an in -house department study that may appraise the
nursing practice of individual nurses.
DIF: Cognitive Level: Knowledge REF: p. 41 OBJ: 4
TOP: Peer review KEY: Nursing Process Step:
N/A MSC: NC LEX: N/A
2. What is the documentation format that uses the acronym SOAPE?
a. Problem-oriented
b. Focused
c. Traditional
d. Crisis
, ANS: A
The problem -oriented medical record uses the acronym SOAPE to
format and for focus charting on a list of patient problems.
DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 7
TOP: Problem-oriented medical record (POMR) KEY:
Nursing Process Step: N/A MSC: NC LEX: N/A
3. Who is the legal owner of the patient’s medical record?
a. Patient
b. Health care provider
c. Institution
d. State
ANS: C
Ownership of a medical record belongs to the institution in the case of
a hospitalized patient, or the health care provider in the case of private
office visits.
DIF: Cognitive Level: Knowledge REF: p. 56 OBJ: 4
TOP: Legal ownership KEY: Nursing Process Step:
Implementation MSC: NC LEX: Psychosocial Integrit y
4. When using electronic (or computerized) documentation, which process
should the nurse use to ensure that no one alters the information the nurse
has entered?
a. Charting in code
, b. Logging off
c. Charting in privacy
d. Signing on with a password
ANS: B
Logging off closes the computer file that was opened with the nurse’s
password. Any other data entry will require that person to sign on with
their password.
DIF: Cognitive Level: Comprehension REF: p. 57 OBJ: 2
TOP: Computer documentation KEY: Nursing
Process Step: N/A MSC: NC LEX: N/A
5. What is the system that classifies patients by age, diagnosis, and surgical
procedure, and produces 300 different categories used for predicting the
use of hospital resources?
a. Qualit y assurance
b. Resource assessment
c. Qualit y improvement
d. Diagnosis-related groups
ANS: D
Cost reimbursement rates under government plans are ba sed on
diagnosis-related groups (DRGs), which is a system that classifies
patients by age, diagnosis, and surgical procedure, producing 300
different categories used in predicting the use of hospital resources,
including length of stay.
Cooper: Foundation of Nursing, 9th Edition
MULTIPLE CHOICE
1. What is the process used to appraise the practice of an individual nurse
known as?
a. Qualit y assurance
b. Incident reporting
c. OBRA
d. Peer review
ANS: D
Peer review is an in -house department study that may appraise the
nursing practice of individual nurses.
DIF: Cognitive Level: Knowledge REF: p. 41 OBJ: 4
TOP: Peer review KEY: Nursing Process Step:
N/A MSC: NC LEX: N/A
2. What is the documentation format that uses the acronym SOAPE?
a. Problem-oriented
b. Focused
c. Traditional
d. Crisis
, ANS: A
The problem -oriented medical record uses the acronym SOAPE to
format and for focus charting on a list of patient problems.
DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 7
TOP: Problem-oriented medical record (POMR) KEY:
Nursing Process Step: N/A MSC: NC LEX: N/A
3. Who is the legal owner of the patient’s medical record?
a. Patient
b. Health care provider
c. Institution
d. State
ANS: C
Ownership of a medical record belongs to the institution in the case of
a hospitalized patient, or the health care provider in the case of private
office visits.
DIF: Cognitive Level: Knowledge REF: p. 56 OBJ: 4
TOP: Legal ownership KEY: Nursing Process Step:
Implementation MSC: NC LEX: Psychosocial Integrit y
4. When using electronic (or computerized) documentation, which process
should the nurse use to ensure that no one alters the information the nurse
has entered?
a. Charting in code
, b. Logging off
c. Charting in privacy
d. Signing on with a password
ANS: B
Logging off closes the computer file that was opened with the nurse’s
password. Any other data entry will require that person to sign on with
their password.
DIF: Cognitive Level: Comprehension REF: p. 57 OBJ: 2
TOP: Computer documentation KEY: Nursing
Process Step: N/A MSC: NC LEX: N/A
5. What is the system that classifies patients by age, diagnosis, and surgical
procedure, and produces 300 different categories used for predicting the
use of hospital resources?
a. Qualit y assurance
b. Resource assessment
c. Qualit y improvement
d. Diagnosis-related groups
ANS: D
Cost reimbursement rates under government plans are ba sed on
diagnosis-related groups (DRGs), which is a system that classifies
patients by age, diagnosis, and surgical procedure, producing 300
different categories used in predicting the use of hospital resources,
including length of stay.
