Chapter 3: Documentation - Nurselytic

Questions 29

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Foundations and Adult Health Nursing Test Bank

Chapter 3 : Documentation Questions

Question 1 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 2 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.

Question 3 of 5

The best defense against malpractice claims associated with nursing care is accurate ____

Correct Answer: documentation

Rationale: Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred.

Question 4 of 5

Twenty-four-hour charting is designed to establish ____ levels to help determine staffing needs.

Correct Answer: acuity

Rationale: Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs.

Question 5 of 5

Documentation using the DARE format (Data Action Response Education) includes elements of the ____ charting system.

Correct Answer: focused

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

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