ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 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 2 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.
Question 3 of 5
What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?
Correct Answer: D
Rationale: The nurse should not read the patient's medical record unless there is a clinical reason for doing so.
Question 4 of 5
Documentation is necessary for the evaluation of patient care. Which of the following phases of the nursing process is necessary for the evaluation of patient care?
Correct Answer: C
Rationale: Documentation is part of the implementation phase of the nursing process.
Question 5 of 5
What does the nurse use as a basis for documentation in focus charting?
Correct Answer: C
Rationale: In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation.