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Which of the following is the MOST accurate description of the purpose of a permanent medical record?

The Joint Commission (TJC) accreditation is MOST dependent on which of the following?

A hospital department is undergoing an audit by TJC. Which outcome would MOST likely cause TJC to withdraw their approval?

Which aspect of nursing documentation is MOST critical for The Joint Commission (TJC) accreditation?

Why is complete and consistent documentation MOST important for reimbursement and utilization review?

Which of the following documentation practices would have the MOST negative impact on reimbursement?

How do the American Nurses Association (ANA) Scope and Standards of Practice relate to documentation?

According to the ANA standards, what characteristic should be present when documenting expected outcomes?

A client's chart indicates a need for scheduled, PRN, and STAT medications. Where would a nurse find this information documented?

A patient is being discharged. Which document would contain a summary of the patient education provided during their stay, including their understanding of the material?

If a patient is unable to make their own healthcare decisions, which document provides instructions about the client's choices for care?

Which of the following best describes the purpose of multidisciplinary progress notes?

A nurse needs to quickly determine a patient's recent fluid intake and output. Which document would be MOST helpful?

Where would a nurse document the specific details of a wound assessment, including size, appearance, and drainage?

A new patient is admitted. Which of the following forms is used to gather baseline information about the client's health patterns and initial physical condition?

A doctor orders a new medication for a client. Where would the nurse look to find the dosage, frequency, and route of administration?

A nurse is preparing a patient for discharge and needs to ensure that necessary referral services are in place. Where would this information be documented?

A patient's lab results return, showing a concerning trend. Where would you find these results in the patient chart?

A nurse is reviewing a patient's chart and notes inconsistent information between the physician's progress notes and the nursing documentation. What is the most appropriate initial action for the nurse to take?

A patient recovering from surgery has a PCA pump for pain management. The nurse notes that the patient is consistently exceeding the hourly limit of the medication. What is the most appropriate nursing intervention?

A nurse is preparing to administer medication to a patient and discovers that the prescribed dose is significantly higher than the usual recommended dose. What is the nurse's priority action?

A nurse is caring for a patient with Down syndrome who has undergone surgery. When documenting the patient's pain level, what adaptation should the nurse make to ensure accurate assessment?

What is the primary reason for documenting patient care thoroughly and accurately?

Which of the following charting notations is the most accurate and objective description of a patient's wound?

A nurse is giving a verbal hand-off report to the oncoming nurse. What information is most essential to include in the report?

A nurse is reviewing a new medication order that is unclear and potentially contains an error. What is the nurse's best course of action?

A patient with a history of diabetes is admitted with hyperglycemia. To effectively track the patient's glucose levels and related interventions using a source-oriented medical record, what approach would be necessary?

In the event of a legal challenge, how would a patient's medical record be used to determine if treatments were carried out appropriately?

How does the use of standardized nursing language within Electronic Health Records (EHRs) contribute to improved patient care and professional accountability?

A nurse documents an assessment finding using a non-standard abbreviation that is misunderstood by a covering physician, leading to a delay in appropriate treatment. This situation primarily violates which principle of documentation?

Which of the following is a primary advantage of using Electronic Health Records (EHRs) over traditional paper-based records in healthcare settings?

A nurse is caring for a patient with complex care needs. The nurse wants to ensure all relevant data regarding the patient's condition and response to treatment is readily accessible to all members of the healthcare team. Which documentation method would be MOST effective in achieving this goal?

A healthcare facility is implementing a new Electronic Health Record (EHR) system. What is a key consideration to ensure the EHR supports quality and performance improvement initiatives, as outlined in Standard 14—Quality of Practice?

A nurse is called to testify in a malpractice lawsuit regarding the care provided to a patient who developed a pressure ulcer during a hospital stay. What aspects of the nurse's documentation will be MOST scrutinized by the legal team?

A patient refuses to take their scheduled oral medication. According to protocol, what is the correct procedure for documenting this refusal?

Which of the following scenarios requires the completion of an incident (occurrence) report?

A patient's medication order includes a dosage range for an IV heart medication that requires titration based on the patient's blood pressure. What specific documentation is essential for this type of medication order?

A patient was scheduled to receive a dose of antibiotics at 0900, but was at dialysis during that time and did not receive it. What documentation is required?

A nurse discovers a patient tripped over an oxygen cord and fell. What information should the nurse include in the incident report?

In home healthcare, what is the primary purpose of the Outcome and Assessment Information Set (OASIS) form?

A patient is admitted to home health care. Which of the following criteria must be met to ensure coverage under Medicare/Medicaid?

What info should be documented regarding injections?

In long-term care (LTC) settings, what is the typical frequency for documenting routine patient services such as wound care, assuming no complications arise?

Which U.S. Government program(s) typically require more detailed documentation in long-term care (LTC) settings?

What is the name of the extensive assessment form that must be completed for residents in long-term care (LTC) facilities upon admission and periodically thereafter?

Which of the following elements is typically included in a weekly summary of a long-term care (LTC) resident's documentation?

In long-term care, how does the frequency of medication administration record (MAR) documentation typically differ from that in acute care settings?

What does the acronym SBAR stand for, in the context of a change-of-shift report?

When providing a change-of-shift report, what information should the nurse clarify before the end of the report?

What does the acronym MBAR stand for, concerning patient transfers?

Documentation

Nurses must be able to

Documentation ABC's

Medical Records

Documentation Importance

Purpose of Documentation

Appendectomy

Steven Vital Signs

Permanent Record

Quality Improvement

The Joint Commission (TJC)

Reimbursement and Utilization Review

Education and Research

Standards of Care

Standard 1—Assessment

Standard 2—Diagnosis

Medical Record (Legal)

Standardized Nursing Language

Nursing Research Support

Electronic Health Records (EHRs)

Source-Oriented Record

Medical Records as Legal Record

Standardized Nursing Language Supports Research

Electronic Health Records (EHR)- chart locations

Injection Documentation

Medication Refusal

Omitted/Delayed Meds

24-Hour Summary

Integrated Plan of Care

Incident Reports

Incident Report Details

Home Health Regs

Admission Data

Advance Directive

History and Physical Examination

Physician's Orders

Progress Notes

Nursing Admission Data Base

Nursing Plan of Care

Graphic Sheet

Daily Assessment Flow Sheet

Medication Administration Record (MAR)

Nursing Process Documentation

Minimum Data Set (MDS)

LTC Weekly Summary

SBAR

MBAR Report

Change of Shift Report

Vital Signs / Assessment

Characteristics of Pain, Medication