Chapter 5: DOCUMENTATION - Nurselytic

Questions 31

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Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills

Chapter 5 : DOCUMENTATION Questions

Question 1 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Why do insurance companies review medical records?

Correct Answer: A,C

Rationale: Insurance companies review medical records for reimbursement based on documented data (
A) and to identify issues for improvement (
C). B is incorrect as consents are not the primary focus, and D is false as records are not owned by insurance companies.

Question 2 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following statement(s) regarding a patient's hospital medical record is(are) accurate?

Correct Answer: C,D,F,G

Rationale: HIPAA ensures patient access to records (
C), originals are hospital property (
D), hospitals must explain health information use (F), and patients can get copies (G). A is false as information is owned by the hospital, B is false as others may access records, and E is false as records are not owned by physicians.

Question 3 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. What is the military time for 1:15 a.m.?

Correct Answer: A

Rationale: 1:15 a.m. is 0115 in military time (
A), as it is 1:15 after midnight. 1315 (
B) is 1:15 p.m., 1115 (
C) is 11:15 a.m., and 1150 (
D) is 11:50 a.m.

Question 4 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. What time would the military time 2210 be?

Correct Answer: B

Rationale: 2210 in military time is 10:22 p.m. (
B), as it is 10 minutes past 10 p.m. 10:22 a.m. (
A) is 1022, 2:21 a.m. (
C) is 0221, and 10:10 p.m. (
D) is 2210.

Question 5 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following would be subjective data?

Correct Answer: A,B

Rationale: Subjective data is reported by the patient, such as pain (
A) or fatigue itching (
B). Grimacing (
C), flushing (
D), blood pressure (E), WBC count (F), and sleeping (G), and snoring (H) are objective, as they can be observed or measured.

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