ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 of 5
The nurse charts only additional treatments done changes in patient condition and new concerns. What is this system of documentation?
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).
Question 2 of 5
What form explains the lapse when events are not consistent with facility or national standards of expected care?
Correct Answer: C
Rationale: An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified.
Question 3 of 5
The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a:
Correct Answer: D
Rationale: Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.
Question 4 of 5
What makes home health care documentation unique?
Correct Answer: C
Rationale: Home health care documentation has unique problems because of the need for different health care workers to access the medical record.
Question 5 of 5
What regulates standards for long-term care documentation?
Correct Answer: A
Rationale: OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation.