ATI LPN
Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 5 : Documentation Questions
Question 1 of 5
Which of the following times during a 7 a.m. to 7 p.m. shift would be appropriate to document on a patient's chart?
Correct Answer: A
Rationale: Documentation should occur as soon as possible after an event to ensure accuracy and timeliness.
Question 2 of 5
Which of the following entries are good examples of succinct charting?
Correct Answer: B, D
Rationale: Succinct charting is specific and concise, like wound measurements or vital signs, avoiding unnecessary detail.
Question 3 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 4 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 5 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.