TEST BANK FOR FUNDAMENTALS OF NURSING 2ND EDITION BY YOOST

Chapter 10: Documentation, Electronic Health Records, and Reporting

Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative

Practice, 2nd Edition

MULTIPLE CHOICE

1. The nurse understands the need for accurate documentation due to which fact?

a. Accurate documentation is needed for proper reimbursement.

b. Accurate documentation must be electronically generated.

c. Accurate documentation does not include e-mails or faxes.

d. Accurate documentation is only accepted in court if written by hand.

ANS: A

Accurate documentation is necessary for hospitals to be reimbursed according to diagnosticrelated groups (DRGs). DRGs are a system used to classify hospital admissions. Health care

documentation is any written or electronically generated information about a patient that

describes the patient, the patient’s health, and the care and services provided, including the

dates of care. These records may be paper or electronic documents, such as electronic medical

records, faxes, e-mails, audiotapes, videotapes, and images. All such records are considered

legal documentation and may be used in court.

DIF: Remembering OBJ: 10.1 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

2. The nurse identifies which statement to be true regarding nursing documentation?

a. Standards for documentation are established by a national commission.

b. Medical records should be accessible to everyone.

c. Documentation should not include the patient’s diagnosis.

d. High-quality nursing documentation reflects the nursing process.

ANS: D

The ANA’s model for high-quality nursing documentation reflects the nursing process and

includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and

retrievability. Standards for documentation are established by each health care organization’s

policies and procedures. They should be in agreement with The Joint Commission’s standards

and elements of performance, including having a medical record for each patient that is

accessed only by authorized personnel. General principles of medical record documentation

from the Centers for Medicare and Medicaid Services (2017) include the need for

completeness and legibility; the reasons for each patient encounter, including assessments and

diagnosis; and the plan of care, the patient’s progress, and any changes in diagnosis and

treatment.

DIF: Understanding OBJ: 10.1 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

3. The nurse identifies which true statement regarding the medical record?

a. It serves as a major communication tool but is not a legal document.

b. It cannot be used to assess quality of care issues.

c. It is not used to determine reimbursement claims.

d. It can be used as a tool for biomedical research and provide education.

ANS: D

The medical record promotes continuity of care and ensures that patients receive appropriate

health care services. The record can be used to assess quality-of-care measures, determine the

medical necessity of health care services, support reimbursement claims, and protect health

care providers, patients, and others in legal matters. It is a clinical data archive. The medical

record serves as a tool for biomedical research and provider education, collection of statistical

data for government and other agencies, maintenance of compliance with external regulatory

bodies, and establishment of policies and regulations for standards of care. The record serves

as the major communication tool between staff members and as a single data access point for

everyone involved in the patient’s care. It is a legal document that must meet guidelines for

completeness, accuracy, timeliness, accessibility, and authenticity. The record can be used to

assess quality-of-care measures, determine the medical necessity of health care services,

support reimbursement claims, and protect health care providers, patients, and others in legal

matters.

DIF: Understanding OBJ: 10.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

4. The nurse knows that paper records are being replaced by other forms of record keeping for

what reason?

a. Paper is fragile and susceptible to damage.

b. Paper records are always available to multiple people at a time.

c. Paper records can be stored without difficulty and are easily retrievable.

d. Paper records are permanent and last indefinitely.

ANS: A

Paper records have several potential problems. Paper is fragile, susceptible to damage, and can

degrade over time. It may be difficult to locate a particular chart because it is being used by

someone else, it is in a different department, or it is misfiled. Storage and control of paper

records can be a major problem.

DIF: Evaluating OBJ: 10.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

5. When the nurse is charting in the paper medical record, what action does the nurse carry out?

a. Print his/her name since signatures are often not readable.

b. Omit nursing credentials since only the nurses chart

c. Skip a line between entries so that it looks neat.

d. Use black ink unless the facility allows a different color.

ANS: D

Entries into paper medical records are traditionally made with black ink to enable copying or

scanning, unless a facility requires or allows a different color. The date, time, and signature,

with credentials of the person writing the entry, are included in the entry. No blank spaces are

left between entries because they could allow someone to add a note out of sequence.

DIF: Remembering OBJ: 10.3 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

6. The nurse is admitting a patient who has had several previous admissions. To obtain a

knowledge base about the patient’s medical history, the nurse would access which document?

a. Electronic medical record (EMR)

b. The computerized provider order entry (CPOE)

c. Electronic health record (EHR)

d. Primary provider’s office notes

ANS: C

The EHR is a longitudinal record of health that includes the information from inpatient and

outpatient episodes of health care from one or more care settings. The EMR is a record of one

episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows

clinicians to enter orders in a computer that are sent directly to the appropriate department. It

does not provide historical data. The primary provider’s office notes may not include all the

patient’s information if the patient has other providers.

DIF: Applying OBJ: 10.2 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

7. The nurse understands which statement about the use of electronic health records is true?

a. They improve patient health status.

b. They require a keyboard to enter data.

c. They have not reduced medication errors.

d. They require increased storage space.

ANS: A

Adoption of an EHR system produces major cost savings through gains in productivity and

error reduction, which ultimately improves patient health status. The most common benefits of

electronic records are increased delivery of guideline-based care, better monitoring, reduced

medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow

simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and

increase portability in environments using wireless systems and hand-held devices. Although

data are often entered by keyboard, they can also be entered by means of dictated voice

recordings, light pens, or handwriting and pattern recognition systems.

DIF: Remembering OBJ: 10.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

8. The nurse is caring for patients on a unit that uses electronic health records (EHRs). What

action by the nurse protects personal health information?

a. The nurse should allow only nurses that he/she knows and trusts to use his/her

verification code.

b. The nurse should not worry about mistakes since the information cannot be

tracked.

c. The nurse should never share any password with anyone.

d. The nurse should be aware that the EHR is sophisticated and immune to failure.

ANS: C

Access to an EHR is controlled through assignment of individual passwords and verification

codes that identify people who have the right to enter the record. Passwords and verification

codes should never be shared with anyone. Health care information systems have the ability to

track who uses the system and which records are accessed. These organizational tools

contribute to the protection of personal health information. Disadvantages of use of computers

for documentation include computer and software failure and problems if there is a power

outage.

DIF: Applying OBJ: 10.4 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

9. The nurse recognizes which statement to be accurate regarding what should be documented?

a. Document facts and subjective data from the patient.

b. Document how he/she feels about the care being provided.

c. Document in a “block” fashion once per shift.

d. Double document as often as possible in order to not miss anything.

ANS: A

Nursing documentation is an important part of effective communication among nurses and

with other health care providers. Documentation should be factual and nonjudgmental, with

proper spelling and grammar. Subjective data from the patient should be included. Events

should be reported in the order they happened, and documentation should occur as soon as

possible after assessment, interventions, condition changes, or evaluation. Each entry includes

the date, time, and signature with credentials of the person documenting. Double

documentation of data should be avoided because legal issues can arise as a result of

conflicting data.

DIF: Remembering OBJ: 10.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

10. The nurse recognizes that nursing documentation is guided by what process?

a. The nursing process

b. NANDA-I, nursing diagnoses

c. Nursing interventions classification

d. Nursing Outcomes Classification

ANS: A

Nursing documentation is guided by the five steps of the nursing process: assessment,

diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such

as the North American Nursing Diagnosis Association–International (NANDA-I) Nursing

Diagnoses, nursing interventions classification (NIC), and Nursing Outcomes Classification

(NOC) may be used in the documentation process.

DIF: Remembering OBJ: 10.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

11. What fact does the nurse know applies to PIE, APIE, SOAP, and SOAPIE documentation?

a. They are chronologic.

b. They are examples of problem-oriented charting.

c. They are narrative charting.

d. They are forms of “charting by exception.”

ANS: B

The nurse’s notes may be in a narrative format or in a problem-oriented structure such as the

PIE, APIE, SOAP, SOAPIE, SOAPIER, DAR, or CBE format. Narrative charting is

chronologic, charting by exception (CBE) is documentation that records only abnormal or

significant data.

DIF: Remembering OBJ: 10.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

12. The nursing instructor teaching students about charting explains that this type of charting

records only abnormal or significant data?

a. PIE

b. SOAP

c. Narrative

d. Charting by exception

ANS: D

Charting by exception (CBE) is documentation that records only abnormal or significant data.

A PIE note is used to document problem (P), intervention (I), and evaluation (E). A SOAP

note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P).

Narrative charting is chronologic, with a baseline recorded on a shift-by-shift basis. Data are

recorded in the progress notes, often without an organizing framework. Narrative charting

may stand alone, or it may be complemented by other tools.

DIF: Remembering OBJ: 10.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Communication

13. Prior to preparing to administer medications to the patient, the nurse should compare the

provider orders with what document?

a. Flow sheet

b. Kardex

c. MAR

d. Admission summary

ANS: C