1. Which of the following does not refer to the process 8. What kind of documentation is the following?

Pain
of adding written information to a health care record? scale 0/10, hand and leg strong to right, weak to left.
A. Recording Skin pink, warm and dry, turgor good, incision to Rt.
B. Charting anterior chest wall erythema or edema
C. Data entry ……………….Jane Night, LPN.
D. Documenting A. Kardex
2. Which of the following statements about documenting B. Narrative
is not true? C. Nurse’s Notes
A. Involves recording the interventions carried out D. Shift report
to meet the patient’s needs. 9. Which of the following practices could lead to
B. Done in a proper way, it reflect the nursing malpractice? Select all that apply
process. A. Charting interventions in advance to save time
C. Necessary to prove that nursing work was done. B. Documenting incorrect data
D. Nursing documentation can be accepted in both C. Not charting the correct time when events took
verbal and written form place
3. Which of the following are basic purposes for an D. Deleting incorrect entries and crossing them out
accurate and complete written patient records? Select all with a horizontal line.
that apply E. Not recording verbal orders or not having them
A. Sometimes used by government agencies to signed.
evaluate patient care 10. Charting that is divided into sections or blocks.
B. It is a permanent record for accountability Emphasis is placed on specific sections, or sheets of
C. It is a legal record of care information. It also uses graphics and narrative charting
D. They are perfect sources for business and A. Traditional Chart
marketing B. Problem-oriented medical record
E. Can be used for research, teaching and data C. Standard form
collection D. Kardex
4. This is the main basis for cost reimbursement rates by 11. Which of the following is a typical section of a
government plans traditional chart? Select all that apply
A. Critical pathway A. Admission sheet and physician’s orders
B. Minimum data sheet B. Progress notes and nurse’s admission
C. Diagnoses related groups information
D. Patient expense documentation C. History and Physical Examination Data
5. Which of the following statements are true regarding D. Medical Administration Record
basic rules for documentation. Select all that apply. E. Care plan and nurse’s notes
A. Use direct quotes for objective assessments 12. Which of the following is considered a traditional
B. If a charting error is made, draw one line charting?
through the faulty information A. Narrative
C. Chart only your own care even when someone B. Problem Oriented Medical Record
else calls you for a late entry. C. SOAPE
D. Chart after care is provided, as soon as possible, D. DARE
and as often as needed 13.What is the difference between Traditional and
E. Sign each block of charting with full legal Problem Oriented medical Record charting?
initials and title A. Traditional uses an abbreviated story form.
6. Based upon the legal guidelines for documentation, POMR uses an outline form
which of the following corrective action is incorrect? B. Traditional uses SOAPE charting. Problems
A. Never erase entries or use correction fluid. oriented medical record uses narrative charting
Never right with a pencil. C. Traditional uses blocks. POMR uses sections.
B. Do not record “physician made error”. D. Traditional focuses on interventions. POMR
C. Be certain that entry is factual even when focuses on interventions.
opinions are used 14. Which of the following are considered the principal
D. While logged into the computer, do not leave sections of a problem-oriented medical record? Select all
terminal unattended even during an emergency. that apply.
7. Which of the following statements about common A. Database
forms of inadequate documentation should not be B. Problem list
included? C. Care plan
A. Not charting correct time when events occurred D. Physical examination and diagnostic tests
B. Failing to record verbal orders or failing to have E. Referral form
them signed 15. Active, inactive potential and resolved problems that
C. Documentation only in hand written format even serve as the index for charting documentation
when EMR is mandated A. Problem assessments
D. Charting actions in advance to save time B. Problem List
E. Documenting incorrect data C. Database
D. Traditional Chart
16. In the SOAPE format, a briefer adaptation of the 22. What is the essential difference between PIE and
POMR, where is Intervention (I) included? SOAPE formats?
A. It is not mentioned in this kind of documentation A. PIE is from a nursing process. SOAPE is from a
B. Included in the notations under PLANNING medical model
C. Included under assessment B. PIE is from a medical model. SOAPE is from a
D. It belongs to another format nursing process
17. In the SOAPE format, if ever there is a need for C. PIE and SOAPE are both used for charting by
changes, where will the REVISIONS (R) be included? exception
A. REVISIONS belong to another format of D. PIE and SOAPE both emerge from the nursing
documentation process
B. REVISIONS are not part of this documentation 23. What kind of notes are taken when charting by
C. REVISIONS are noted in the EVALUATION exception? Select all that apply.
section A. Additional treatments done or planned
D. REVISIONS are noted in the ASSESSMENT treatments withheld
section B. Standing orders and physical history
18. Which of the following statements about FOCUS C. New Concerns
CHARTING is incorrect? D. Changes in patient condition
A. Uses the nursing process and the more positive 24. In charting by exception, what happens after the
concept of patient needs patient’s problem is resolved?
B. Focus is sometimes a current patient concern or A. It needs to be a part of the SOAPE
behavior. documentation
C. Focus is sometimes a significant changes in B. It needs to be explained to the next shift
patient status or behavior or a significant event C. It is no longer covered by daily documentation
in the patient’s therapy. D. It needs to be transferred to a permanent record
D. Focus can be a medical diagnosis 25. Which of the following are considered examples of
19. Which of the following statements regarding the record keeping forms? Select all that apply.
DARE format of documentation are correct? Select all A. Kardex or Rand
that apply B. Nursing Care Plan
A. Data, action, response and evaluation, education C. Incident Reports
and patient teaching D. 24-hour patient care and acuity charting
B. Data is both subjective and objective E. Discharge summary
C. Action combines planning and implementation 26. A system used to consolidate patient orders and care
D. You need to use all the DARE steps each time needs in a centralized, concise way.
you make notes on a particular focus A. Incident Reports
E. Response is the same as evaluation and B. Kardex or Rand System
effectiveness C. Intervention Guidelines
F. Some facilities include education or patient D. Nursing Care plan
teaching 27. Preprinted guidelines used to care for patients with
20. There are facilities that require narrative notes for similar health problems.
each shift to include a minimum of at least three entries. A. Nursing Care Plan
Legally, care is not given if care is not charted. This is B. Kardex
true but it is time consuming and requires excessive C. Common illness index
detail and a defensive manner in doing so. To solve this D. Health intervention reference
issue, what did some hospitals come up with? 28. Developed by nurses for nurses, it is based on
A. CBE nursing diagnoses and nursing assessment. It also
B. DOA includes, goals, plans for care and specific actions for
C. ABC care implementation and evaluation
D. APIE A. Standardized nursing care plans
21. Which of the following formats is included under B. Plans written in nursing notes
Charting be exception? Select all that apply. C. Narrative planning
A. PIE D. Kardex or Rand
B. SOAPE 29. What do you have to fill up when an event transpired
C. SOAPIER is not consistent with routine operation of a health care
D. APIE unit or routine care of a patient or other hospital
notification form when patient care delivered is not
consistent with facility or national standards of expected
care. These events have the potential to cause injury.
A. Injury reports
B. Incident reports
C. Intervention reports
D. Implementation reports
30. Which of the following should not be considered 37. Which of the following statements about home
when filling up an incident report? health care are true? Select all that apply
A. Do not admit liability or give unnecessary A. It provides a narrower scope of people for a
details wider majority of services.
B. List date, time and care given to the patient and B. Requires a whole health care team to work
the name of the Physician notified. closely
C. Personal assessment and judgment of incident C. Does not demand meticulous and thorough
D. When charting the incident in the patient’s documentation
nursing notes, do not mention the incident D. Duplication of documentation is difficult to
report. avoid
31. Benefits of a 24-hour patient care records. Select all 38. Required by the Omnibus Budget Reconciliation Act
that apply: primarily for Long Term Care facilities
A. Helps eliminate unnecessary record keeping A. MDS
forms B. DRG
B. Enhances efficiency because flow sheets and C. BCG
checklists are often used. D. NCLEX
C. Accommodates a 24-hour period 39. An irate patient tells a clerk, “I have paid too much
D. Necessary to maintain a good nursing care plan every time I came to this clinic for a physical
32. Uses a score that rates each patient by severity of examination. I think my medical records belong to me. I
illness. need them now”. What would be the best response.
A. Acuity charting A. I am required to give you a request form so that
B. Charting by exception I can prove you wanted your records and not just
C. Critical pathway anyone else.
D. Traditional Charting B. Your original health care record belongs to the
33. One of the benefits of acuity charting is that it Physician.
provides us with the ability to determine efficient C. One moment, let me make a copy of it
staffing patterns according to the acuity levels of the immediately. How many do you want?
patients on a particular nursing unit. D. I am so sorry but you really do not have a right
A. True to look at your own records.
B. False 40. Patients usually do not have immediate access to
34. When does discharge planning ideally begin? their full records. There is one exception. What is it?
A. During admission A. County hospitals such as Stroger’s Hospital
B. After admission B. University clinics such as PCCTI Nursing lab
C. Before admission C. Federal Health Care Agencies such as VA
D. Without admission hospitals
35. A systematic approach to care that provides a D. Municipal Health Care Centers such as
framework for the coordination of medical and nursing Oakbrook Health Center
interventions. 41. What does HIPAA mandate health care personnel
A. Managed care with regards to patient’s records?
B. Critical pathway A. Privacy
C. Acuity Care B. Accessibility
D. Intensive care C. Confidentiality
36. Which of the following statements about Clinical D. Availability
(Critical Pathway) are true? Select all that apply: 42. What do Electronic Medical Records require from
A. Allows staff to develop standardized integrated the health care personnel?
care plans for a projected length of stay for A. Log into the system with a secure password
patients of a specific case type. B. Log into the system with a common password
B. Clinical pathways that delve with cases occur in C. Log into the system with a borrowed password
high volume and are predictable. D. Log into the system with a friend’s password
C. The clinical pathway replaces other nursing 43. The government reimburses agencies for health care
forms such as the nursing care plans costs incurred by Medicare and Medicaid recipients
D. Charting by exception is usually the method based on:
used for clinical pathways A. Documentation by the nurse
E. The exact contents and format of these clinical B. Appropriate physician progress notes
pathways are the same among different C. Diagnosis-related groups
institutions. D. Minimum data sheets
44. While doing clinicals, your nurse preceptor had to Answers
leave her station immediately due to a code overheard on 1. C. Data entry
the public address system. You observed that the 2. D. Nursing documentation can be accepted in both
computer monitor displayed a patients medical history. verbal and written form.
This patient was not assigned to your care. What should 3. A,B,C,E.
you do next? 4. C. Diagnoses related groups
A. Read the medical history for your own 5. B,C,D. Use direct quotes for subjective assessment.
education. Sign each block of charting with full initials and title.
B. Turn off the computer as soon as possible 6. C. Be certain that entry is factual even when opinions
C. Print the document to serve as future reference are used.
D. Call your clinical instructor and ask what to do 7. C. Documentation only in hand written format even
45. When is it unnecessary to chart a narrative note? when EMR is mandated
Select all that apply. 8. B. Narrative
A. Each time you give a medication 9. A,B,C, E.
B. Each time a bath is given 10. A. Traditional Chart
C. Each time a decubitus ulcer changes in 11. A,B,D,E
appearance 12. A. Narrative
D. Each time you assess vital signs 13. A. Traditional uses an abbreviated story form.
POMR uses an outline form
14. A,B,C,D
15. B. Problem List
16. B.  Included in the notations under PLANNING
17. C. REVISIONS are noted in the EVALUATION
section
18. D. Focus can be a medical diagnosis
19. A,B,C,E,F
20. A. CBE
21. A,D
22. A. PIE is from a nursing process. SOAPE is from a
medical model
23. A,C,D
24. C. It is no longer covered by daily documentation
25. A,B,C,D,E
26. B. Kardex or Rand System
27. A. Nursing Care Plan
28. A. Standardized nursing care plans
29. B. Incident reports
30. C. Personal assessment and judgment of incident
31. A,B,C.
32. A. Acuity charting
33. A. True
34. A. During admission
35. A. Managed care
36. A,B,C,D
37. A,B,D
38. A. MDS
39. A. I am required to give you a request form so that I
can prove you wanted your records and not just anyone
else.
40. C. Federal Health Care Agencies such as VA
hospitals
41. C. Confidentiality
42. A. Log into the system with a secure password
43. C. Diagnosis-related groups
44. B. Turn off the computer as soon as possible. It is the
ethical thing to do to show respect to patient’s
confidentiality.
45. A,B,D.