Documentation EAQ- Final

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Questions and Answers

Which item is a feature of charting by exception? SATA

  • documentation of deviations (correct)
  • use of shorthand method (correct)
  • documentation of significant findings (correct)
  • narrative description of exceptions (correct)

Which information would the nurse provide int he discharge summary for a patient discharged home? SATA

  • The contact information of the healthcare provider. (correct)
  • The instructions for self-administration of insulin. (correct)
  • The signs and symptoms that have to be reported to the healthcare provider. (correct)

Which type of documentation is based on the concept that all standards for normal assessment findings or for routine care activities are met unless otherwise documented?

  • charting by exception (correct)

Which action would the nurse take when documenting patient care? SATA

<p>Record factual information (A), Record handwritten entries legibly and in black ink (B), Begin each entry with date and time and end with signature and title (C)</p> Signup and view all the answers

Which standardized assessment tools are used for receiving health care funding from the Centers for Medicare and Medicaid Services? Select all that apply.

<p>Resident Assessment Instrument. (A), Minimum data set. (B)</p> Signup and view all the answers

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