ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 of 5
What is the purpose of QA (quality assurance)?
Correct Answer: B
Rationale: QA is an in-house department that evaluates care services and results against accepted standards.
Question 2 of 5
What is the process used to appraise the practice of an individual nurse known as?
Correct Answer: D
Rationale: Peer review is an in-house department study that may appraise the nursing practice of individual nurses.
Question 3 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 4 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 5 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.