Chapter 3: Documentation - Nurselytic

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).

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.

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.