Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Incident reports must be recorded in the nurse's notes

Institutions are only reimbursed for patient care that is documented

Document only when not successful

The patient record is a complete picture of individualized problems, treatments and responses to treatments

Answer and Explanation

Correct Answer : B,D

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

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Correct Answer is C

Explanation

A. Ensure subjective documentation: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) promotes objective documentation to ensure accuracy and reliability in patient care records.

B. Make sure that all nurses use the same charting system: JCAHO does not mandate a uniform charting system, as institutions may use different electronic health record (EHR) systems.

C. Ensure quality patient care: JCAHO’s primary role is to establish and enforce standards to improve patient safety and healthcare quality.

D. Make sure insurance companies get paid correctly: JCAHO’s focus is on patient care quality, not financial reimbursement.

A. interview and physical examination B. review of the doctor's orders and the Kardex C. written report by patient and family D. review of the chart and the nurse's notes

Correct Answer is A

Explanation

A. Interview and physical examination: The two primary methods of data collection in nursing are:

Interview (subjective data: patient history, symptoms, concerns)
Physical examination (objective data: vital signs, assessment findings)

B. Review of the doctor's orders and the Kardex: This provides supplementary data but does not directly collect patient information.

C. Written report by patient and family: This may provide valuable subjective data but is not a primary method of data collection.

D. Review of the chart and the nurse’s notes: This is reviewing existing documentation, not actively collecting data.

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Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

JCAHO regulates standards of care to:

Correct Answer is C

Explanation

Identify the two primary methods used to collect data:

Correct Answer is A

Explanation

When using the SOAP method of charting, S stands for subjective data which means:

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)

One benefit of computerized charting is that:

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

Patient health care records are: