Chapter 3: Documentation - Nurselytic

Correct Answer: focused

Rationale: Focused charting uses the acronym DARE to direct and formalize charting.

Correct Answer: quality assurance

Rationale: Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. This process ensures that care delivery meets established benchmarks, identifying areas for improvement to maintain high-quality patient care.

Correct Answer: C

Rationale: Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include health care provider's visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive.

Correct Answer: B

Rationale: Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.

Correct Answer: C

Rationale: Charting additional treatments done, changes in a patient's condition, and new concerns during the shift is charting by exception (CBE).