Test Bank For Nursing Health Assessment A Best Practice Approach 1st edition by Jensen
Chapter 05- Documentation and Interdisciplinary Communication
1.
The medical record serves many purposes. What are they? (Select all that apply.)
A)
Framework for medical information
B)
Means for financial reimbursement
C)
Research
D)
Care planning
E)
Information for the family
2.
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
A)
To provide a record of the nurse’s activities
B)
To provide a record of the actual events
C)
To provide a record of how the patient was harmed
D)
To provide a record of the physician’s activities
3.
Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit?
A)
The evaluation of financial reimbursement
B)
The evaluation of patient nutrition
C)
The evaluation of care for continual improvement
D)
The evaluation of timely documentation of pain
4.
Why do nursing students review medical records? (Select all that apply.)
A)
To enhance clinical learning
B)
To compare nursing care provided to patients
C)
To evaluate the plan of care for a specific patient
D)
To verify that laboratory results are accurate
E)
To better understand complex clinical situations
5.
The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
A)
Safety among patient populations decreases
B)
Pharmacy orders are electronically verified
C)
Physician notes are more secure
D)
Patient safety increases
6.
A clinical instructor is discussing with students the care provided to a patient. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student’s best answer?
A)
To have up-to-date information on which to base clinical decisions
B)
To be able to verify what care has been given
C)
To communicate with other health care providers
D)
To be able to update the plan of care
7.
The Joint Commission, in 2006, developed a National Patient Safety Goal. What is a requirement of this goal?
A)
Health care agencies need to standardize their charting
B)
Health care agencies need to develop a standardized approach to hand off communications
C)
Health care agencies need to conform to Joint Commission communication templates
D)
Health care agencies need to computerize medical records
8.
One of the goals of nursing is to provide care that is safe to patients. What is the best way for nurses to realize this goal?
A)
By accurately charting patient care
B)
By continually assessing patient laboratory values
C)
By continual communication with all members of the health care team
D)
By giving patient care conferences including all members of the health care team
9.
A new graduate nurse has just started working. The new nurse asks a more experienced nurse to explain SOAP charting. What would the second nurse explain that the A in SOAP stands for?
A)
Analysis of data to identify a problem
B)
Assessment of subjective data
C)
Assessment of objective data
D)
Articulation of the plan of treatment
10.
When an agency has policies that require nurses to write focus notes, the nursing documentation can include what?
A)
Areas of personal accomplishments
C)
Social networks
B)
Areas of personal weakness
D)
Family concerns
11.
When a nurse works in a health care agency that charts by exception (CBE), he or she knows that the patient assessment is structured by what?
A)
Medical diagnoses
C)
Standardized norms
B)
Patient needs
D)
Joint Commission standards
12.
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