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. 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 2 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 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 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 4 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 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 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.

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

Access More Questions!

ATI LPN Basic

ATI LPN Premium

Similar Questions