ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 5 : Documentation Questions
Question 1 of 5
What type of documentation would you, as a nurse, be responsible for performing in the section marked Physician's Orders?
Correct Answer: C, D, E
Rationale: Nurses document transcription details, noting of orders, and verbal orders in the Physician's Orders section.
Question 2 of 5
In a source-oriented medical record, which of these would be found in the Nurse's Notes section?
Correct Answer: A, C, F
Rationale: Nurse's Notes include nurse assessments, patient responses, and patient complaints, not HCP data, living wills, or diagnostic reports.
Question 3 of 5
Which document would be found in the Advanced Directive section of a source-oriented medical record?
Correct Answer: B
Rationale: The Advance Directive section contains documents like living wills, which outline patient preferences for care.
Question 4 of 5
Which setting(s) may use Kardexes and paper charts?
Correct Answer: A, B, C, D
Rationale: Kardexes and paper charts may be used in various settings, including hospitals, surgery centers, home health, and long-term care.
Question 5 of 5
When working in long-term care, the nurse is required to document assessment data on a resident how often?
Correct Answer: D
Rationale: In long-term care, resident assessments are typically documented monthly unless otherwise specified.