Chapter 5: DOCUMENTATION

Question 1 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that needs to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective.

A. Snored loudly most of night between 0030 and 0530.B. Green purulent drainage increased from yesterday. ABD pad has 6' circle of drainage.C. Procedure tolerated well.D. ADA diet-ate 75% tolerated poorly.E. Bouncing foot almost continually. Rubbing hands and flicking finger with thumb at intervals. Verbally denies feeling nervous or anxious.F. Got mad while ambulating in the hall.G. Has a bad attitude.

Correct Answer: C,D,F,G

Rationale: Subjective terms: 'tolerated well' (
C), 'tolerated poorly' (
D), 'got mad' (F), 'bad attitude' (G). These should be replaced with objective descriptions. A, B, and E are objective.

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 entries are succinct?

A. I took her temp and it was up to 104.2 degrees Fahrenheit.B. After giving a complete bed bath, oral care was performed with toothpaste, toothbrush, and mouthwash. Lotion was applied liberally over arms, back, legs, feet, and hands. Her feet and back were massaged for quite a while.C. 18 Fr. Foley cath inserted without difficulty & hung to gravity drainage. Returned 275 mL clear pale yellow urine.D. The patient said she is really nauseated badly but that she hasn't vomited yet. She asked for her nausea medication that comes in an injection.E. C/O constant sharp, stabbing pain in Rt. great toe, began 1 hr ago, now a 7 on 0-10 scale.

Correct Answer: C,E

Rationale: Succinct entries are the Foley catheter insertion (
C) and pain complaint (E). A is informal, B is overly detailed, and D is wordy.

Question 3 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of the following is(are) a purpose of documentation?

A. To provide a record for administration to prove that the nurses have earned their payB. To provide a permanent record of medical diagnoses, nursing diagnoses, plan of care, care provided, and the patient's response to that careC. To serve as a punitive measure for nurses who will not do all the interventionsD. To serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes

Correct Answer: B,D

Rationale: Documentation serves as a permanent record of patient care (
B) and supports accountability for quality assurance, accreditation, and reimbursement (
D). A is incorrect as documentation is not about proving nurses' pay, and C is incorrect as it is not a punitive measure.

Question 4 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. The process of providing effective patient care that is delivered and evaluated continuously, systematically, and smoothly from one hour to the next, including through the staffing changes between shifts, is known as what?

A. Internal assessmentB. AccreditationC. Quality assuranceD. Continuity of care

Correct Answer: D

Rationale: Continuity of care (
D) ensures patient care is delivered consistently across time and staff changes. Internal assessment (
A), accreditation (
B), and quality assurance (
C) are related to evaluation and standards but not the direct process of care delivery.

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 statements is(are) true in reference to The Joint Commission?

A. The Joint Commission audits medical records to verify facility compliance in meeting established healthcare standards.B. The Joint Commission sets the standards by which the quality of health care is measured nationally and internationally.C. The Joint Commission seeks to improve safety and quality of care that health-care organizations provide to the public.D. The Joint Commission is a group of commissioned individuals who collectively represent all the medical insurance companies who set the standards for medical care reimbursement.

Correct Answer: A,B,C

Rationale: The Joint Commission audits records (
A), sets healthcare quality standards (
B), and aims to improve safety and quality (
C). D is incorrect as it does not represent insurance companies.

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