Chapter 3: Documentation - Nurselytic

Questions 29

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Chapter 3 : Documentation Questions

Question 1 of 5

What is the documentation format that uses the acronym SOAPE?

Correct Answer: A

Rationale: The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems.

Question 2 of 5

Who is the legal owner of the patient's medical record?

Correct Answer: C

Rationale: Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the health care provider in the case of private office visits.

Question 3 of 5

When using electronic (or computerized) documentation which process should the nurse use to ensure that no one alters the information the nurse has entered?

Correct Answer: B

Rationale: Logging off closes the computer file that was opened with the nurse's password. Any other data entry will require that person to sign on with their password.

Question 4 of 5

What is the system that classifies patients by age diagnosis and surgical procedure and produces 300 different categories used for predicting the use of hospital resources?

Correct Answer: D

Rationale: Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.

Question 5 of 5

A nurse is using the data action response education (DARE) system of charting and is completing the data portion. What data are the nurse's focus?

Correct Answer: B

Rationale: DARE is the acronym for four different aspects of charting using the focus format. Data (
D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (
A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E).

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