ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 of 5
A nurse is receiving a telephone order from a health care provider. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the second step of this method?
Correct Answer: B
Rationale: SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during 'hand-off' or 'handover' interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional 'R' is added. The additional 'R' (SBARR) represents 'read back' when the nurse reads back the order for clarification.
Question 2 of 5
What are categories of inadequate documentation that may lead to a malpractice claim?
Correct Answer: A,B,C,D
Rationale: Marking out with a single line and initialing is an acceptable method to indicate a charting error.
Question 3 of 5
What are some problems associated with electronic (or computerized) charting?
Correct Answer: A,B,E
Rationale: Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages.
Question 4 of 5
What are the basic purposes of written patient records?
Correct Answer: A,B,C,D,E
Rationale: There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection.
Question 5 of 5
What should a medical record provide for all health care providers?
Correct Answer: A,B,C,D,F
Rationale: A medical record should furnish all health care providers with a concise, accurate, written picture of a patient's medical and nursing problems, care planned and given, and the patient's response to treatments.