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. Which are accurate statements about EHR?

Correct Answer: B,D

Rationale: EHR is a lifetime health record (
B) and nurses should only access assigned patients' records (
D). A is false as it includes specialists, C is false as precautions are needed, and E is false as EHR is not limited to hand-held devices.

Question 2 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. In which facilities might EHR be used?

Correct Answer: A,B,C,D,E

Rationale: EHR is used in hospitals (
A), clinics (
B), labs (
C), pharmacies (
D), and home health (E) for comprehensive health data management.

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 rule(s) do(es) not apply to paper documentation?

Correct Answer: D

Rationale: Subjective data documentation is not limited to verbal reports (
D). All other options (A, B, C, E, F, G) are standard paper documentation rules.

Question 4 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Guidelines for paper documentation include which of the following?

Correct Answer: A,D

Rationale: Paper documentation requires signing at shift's end (
A) and including date/time (
D). Cursive is not mandatory (
B), and block charting (
C) is not standard.

Question 5 of 5

Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. The correct signature for documentation includes which of the following?

Correct Answer: A,E

Rationale: Correct signatures include first and last names (
A) or first initial, last name, and credentials (E). B, C, and D do not meet standard documentation requirements.

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