Chapter 5: DOCUMENTATION

Chapter 5: DOCUMENTATION - Nurselytic

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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 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.

Question 2 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?

A. Reimbursement is dependent on documentation of specific data in the medical record.B. Insurance reimbursement depends on the specific consents that the patient or family members have signed.C. Records help insurance companies to detect problems, less-than-desirable outcomes, or areas of weakness in the delivery systems so that improvements can be made.D. Because the medical record is the property of the patient's insurance company.

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 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 statement(s) regarding a patient's hospital medical record is(are) accurate?

A. All the information within the chart belongs to the patient.B. Access to a patient's medical record is restricted to the physician, the nurse, and the patient.C. HIPAA guarantees the patient the right to view his or her own medical record.D. The patient may not take the original medical record because it is the property of the hospital.E. The medical record belongs to the admitting physician.F. The hospital must provide the patient with a written explanation of how the patient's health information will be used.G. The patient has the right to a copy of any or all of his or her own medical records.

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 4 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.?

A. 115B. 1315C. 1115D. 1150

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 5 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?

A. 10:22 a.m.B. 10:22 p.m.C. 2:21 a.m.D. 10:10 p.m.

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.

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Chapter 5: DOCUMENTATION - Nurselytic

Nurselytic

ATI LPN

ATI LPN

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

Chapter 5 : DOCUMENTATION Questions

Question 1 of 5

Question 2 of 5

Question 3 of 5

Question 4 of 5

Question 5 of 5

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