ATI LPN
Study Guide for Fundamentals of Nursing Care: Concepts, Connections & Skills
Chapter 5 : DOCUMENTATION Questions
Question 1 of 5
Indicate whether the following statements are True (T) or False (F). If your cursive writing is not legible, you must print your documentation on a paper chart.
Correct Answer: A
Rationale: True (T): Legibility is critical, so printing is required if cursive is unreadable.
Question 2 of 5
Indicate whether the following statements are True (T) or False (F). The only time that it is okay to share your computer password with another student or coworker is if he or she is going to document vital signs for you.
Correct Answer: B
Rationale: False (F): Sharing passwords is never acceptable due to security and accountability concerns.
Question 3 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When documenting with focus charting, which acronym is generally used?
Correct Answer: D
Rationale: Focus charting uses the DAR (Data, Action, Response) acronym (
D). SOAP (
A), SOAPIER (
B), and PIE (
C) are used in other charting methods.
Question 4 of 5
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
Correct Answer: B
Rationale: Logging off (
B) prevents unauthorized access and alterations. Charting in code (
A) is not standard, privacy (
C) is important but not preventive, and passwords (
D) are for access, not alteration prevention.
Question 5 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.