ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 3 : Documentation Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as ____
Correct Answer: quality assurance
Rationale: Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. This process ensures that care delivery meets established benchmarks, identifying areas for improvement to maintain high-quality patient care.