Nursing Documentation Quiz
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Questions and Answers

What is one of the essential purposes of accurate and comprehensive recording in patient documentation?

  • To support investigations such as legal inquiries (correct)
  • To create a casual record of patient visits
  • To restrict access to patient information
  • To provide entertainment for the medical staff

    • Only certain categories of nurses are responsible for recording nursing interventions.

    False

    What must be recorded in patient documentation regarding any abnormalities?

    The specific abnormality, the person whom it was reported to, and relevant nursing interventions.

    All patient documentation must reflect a complete picture of the entire period of __________ in a legal and valid manner.

    <p>hospitalisation</p> Signup and view all the answers

    Match the following elements of nursing documentation with their descriptions:

    <p>Patient records = Reflect the nursing care rendered Mediclinic approved records = Must be the only records used Admission and discharge diagnoses = Should be recorded in the documentation Communication with the team = Essential for delivering effective patient care</p> Signup and view all the answers

    Which option is NOT a recommended practice for patient documentation?

    <p>Using checks (√) and crosses (×) in assessment documents</p> Signup and view all the answers

    Patient documentation is only important for billing purposes.

    <p>False</p> Signup and view all the answers

    What must nursing practitioners comply with regarding clinical records?

    <p>Legal requirements and standards related to record keeping.</p> Signup and view all the answers

    What is NOT considered a diagnosis according to the admission criteria?

    <p>Appendectomy</p> Signup and view all the answers

    A full signature and personnel number are required on the Signature Sheet.

    <p>True</p> Signup and view all the answers

    What types of history should be collected during the clinical assessment?

    <p>Current, Medical, Surgical, Travel, Family</p> Signup and view all the answers

    The four physical examination techniques include inspection, percussion, palpation, and ______.

    <p>auscultation</p> Signup and view all the answers

    Match the following types of history with their descriptions:

    <p>Current = Reason for hospital admission Medical = Past health conditions Surgical = Previous surgeries performed Family = Health issues in family history</p> Signup and view all the answers

    Which of the following is considered objective data during a clinical assessment?

    <p>Presence of cyanosis</p> Signup and view all the answers

    A clinical assessment can take place immediately upon patient admission.

    <p>False</p> Signup and view all the answers

    During the clinical assessment, using all ______ is essential for a thorough examination.

    <p>senses</p> Signup and view all the answers

    What does systolic pressure indicate?

    <p>The peak pressure during left ventricular contraction</p> Signup and view all the answers

    A normal adult pulse rate is considered to be between 80 to 120 beats per minute.

    <p>False</p> Signup and view all the answers

    What happens to the pulse when it is palpated?

    <p>It should be strong and regular.</p> Signup and view all the answers

    Reasons for ______ include inflammatory response and sepsis.

    <p>pyrexia</p> Signup and view all the answers

    Which of the following is NOT a reason for hypothermia?

    <p>Drug reaction</p> Signup and view all the answers

    Match the following vital sign measurements with their descriptions:

    <p>Blood Pressure = Pressure exerted by blood on arterial walls Pulse Rate = Number of heartbeats per minute Temperature = Indication of body heat Pain Intensity = Subjective measure reported by the patient</p> Signup and view all the answers

    It is necessary to write down the actual values for vital sign measurements.

    <p>False</p> Signup and view all the answers

    What should be assumed if pain is new or cannot be relieved with normal analgesia?

    <p>It may indicate a problem.</p> Signup and view all the answers

    What does the 'R' in SMART principles stand for?

    <p>Realistic</p> Signup and view all the answers

    Nursing prescriptions should be vague and open-ended.

    <p>False</p> Signup and view all the answers

    What is the primary role of a nurse when supporting patients and their families emotionally?

    <p>To listen attentively and empathetically.</p> Signup and view all the answers

    A patient care plan provides written, detailed instructions on activities nurses should implement to help a patient reach expected __________.

    <p>outcomes</p> Signup and view all the answers

    Match the following components of nursing prescriptions with their correct descriptions:

    <p>Specific = Clearly defines what needs to be done Measurable = Establishes how progress will be tracked Attainable = Ensures the goal can realistically be achieved Time bound = Sets a timeframe for completion</p> Signup and view all the answers

    Which of the following is an example of a SMART nursing prescription?

    <p>Weigh patient daily at 6:00</p> Signup and view all the answers

    A nursing prescription is activated with a checkmark and deactivated with a line drawn through it.

    <p>True</p> Signup and view all the answers

    What should be documented by the nurse who completes the basic needs care plan?

    <p>Date, time, initials, and surname.</p> Signup and view all the answers

    Which of the following is NOT included in the definition of output?

    <p>Intake of solid food</p> Signup and view all the answers

    A patient sticker should be placed in the space provided to identify the document.

    <p>True</p> Signup and view all the answers

    What should be recorded if a patient has no known allergies?

    <p>'no known allergies' in black pen or a green sticker</p> Signup and view all the answers

    The totals for ______ and the totals for ______ should be added to determine fluid balance.

    <p>intake, output</p> Signup and view all the answers

    What must be completed before the patient receives any pre-medication?

    <p>Consent confirmation</p> Signup and view all the answers

    Match the documentation requirements with their correct descriptions:

    <p>Patient sticker = Identifies the document Green sticker = Indicates no known allergies Red sticker = Indicates patient allergies Consent confirmation = Verifies understanding of the procedure</p> Signup and view all the answers

    The nurse is responsible for writing what the patient consented to and what procedure is stated in the theatre list.

    <p>True</p> Signup and view all the answers

    What is used to record different types of output, such as urine or vomitus?

    <p>Different columns for each type of output</p> Signup and view all the answers

    What should be added to individualize the care plan for potential urinary retention?

    <p>Minimum urinary output in ml/hour</p> Signup and view all the answers

    Nursing prescriptions do not need to be initialed if they are ticked or activated.

    <p>False</p> Signup and view all the answers

    What should be done to ensure patient comfort regarding positioning?

    <p>Ensure head, back, and buttocks are in line and support the patient with pillows.</p> Signup and view all the answers

    The expected outcome for urinary output should be a minimum of _____ ml/hour.

    <p>30</p> Signup and view all the answers

    Match the potential complications with the appropriate nursing actions:

    <p>Potential wound infection = Add parameters for temperature Potential urinary infection = Tick/activate applicable nursing prescriptions Potential respiratory complications = Insert expected O2 saturation Potential nausea = Add information in open spaces</p> Signup and view all the answers

    Which of the following is NOT a component of the nursing documentation guidelines?

    <p>Add emotional support measures</p> Signup and view all the answers

    Recording the volume of emptied urinary catheter on the fluid balance record is unnecessary.

    <p>False</p> Signup and view all the answers

    What should be added to nursing prescriptions related to potential phlebitis or infiltration?

    <p>Information in open spaces to individualize the care plan.</p> Signup and view all the answers

    Study Notes

    Guideline to the Completion of Patient Documentation

    • This document guides users in completing adult patient nursing and clinical records, ensuring consistent and accurate completion in all clinical facilities.
    • Accurate and comprehensive recording is crucial for: describing patient condition, treatment plan, interventions, and patient responses; ensuring effective communication among care team members; supporting investigations, legal issues, and complaints; informing medical aid authorizations and billing; and providing data for clinical coding, statistics, funding, and strategic decisions.
    • This policy applies to nursing practitioners and users recording information in adult patient records.

    Table of Contents

    • The document includes a detailed table of contents listing various sections related to completing patient documentation for adult patients in several clinical settings.
    • Specific record types such as the General Assessment Record (N0953), Waterlow Pressure Sore Risk Assessment (N3297), Venous Thrombo-Embolism (VTE) Risk Assessment (N3297), are highlighted with corresponding page numbers, indicating the different sections of the document.

    General Information

    • This section outlines the purpose of patient documentation, emphasizing its role in accurate and consistent record-keeping in all clinical settings. This document is a comprehensive guideline, used to ensure the correct method of keeping patient information.
    • The document encompasses the legal and clinical requirements that govern record keeping.
    • Essential elements of quality include patient responses to nursing care and treatment, and multidisciplinary team communication.
    • Mediclinic approved patient records are specified, with details about not using ticks or crosses to indicate choices in assessment documents and what information should be avoided.

    Critical Elements in Documentation

    • The document covers key terms in patient documentation, including legibility, accuracy, conciseness, credibility, and chronological order.
    • It emphasizes the importance of clear, permanent records, free from errors.
    • Documentation must accurately reflect nursing care rendered, patient responses to care and treatment, and communication with the multidisciplinary team.
    • This must be presented in a patient-centered, logical, and sequential manner, contemporaneously or as events happen.
    • Details regarding the formatting, and completion of specific sections of the document are provided.

    Completion: General Assessment Record (N0953)

    • Information on how patients are welcomed and oriented is presented in the section relating to general patient assessment forms.
    • The section explains that the record is divided into sections and used for both admission centers and direct admissions in a nursing unit.
    • Recording patient-related information on these forms is essential.

    Completion: Waterlow Pressure Sore Risk Assessment (N3297)

    • The document details using a form to assess patient risk for developing pressure sores.
    • Records the date and time of the assessment.
    • This information is to help determine if patients need additional care measures.

    Completion: Venous Thrombo-Embolism (VTE) Risk Assessment (N3297)

    • This section provides details on assessing a patient's risk of developing a thrombosis.
    • Guidelines for recording date, time and criteria with scores are included.

    Completion: Signature Sheet (N3373)

    • This form ensures all members of the multidisciplinary team who record patient information sign the sheet.
    • Record relevant details such as employee/agency number, initials and surname.

    Completion: Adult Early Warning Observation Record (N3182)

    • The document outlines the use of a record for identifying patients at risk of deterioration.
    • Also provides direction for nurse practitioners on appropriate interventions and documentation.
    • The record should include the time of observations and any related nursing interventions.

    Completion: Patient Care Plan Basic Needs (N0909)

    • Describes the use of basic care plan for patients to document their hygiene needs.
    • Outlines activation and deactivation of nursing prescriptions and necessary details.

    Completion: Specific Patient Care Plan (N1012)

    • This section details the inclusion of SMART principles in nursing prescriptions.
    • Explicit examples of specific, measurable, attainable, realistic, and time-bound prescriptions are demonstrated.

    Completion: Fluid Balance Record (N0949)

    • This explains the importance of documenting fluid intake and output, a critical measure for patient wellbeing.
    • This includes details of recording and documenting times of intake and output.

    Completion: Peri-Operative Record (N0997)

    • This form focuses on pre-operative consent for patient procedures/surgeries
    • Details on recording allergies, patient consent with the procedure, and recording risk factors.
    • Includes essential details for pre-op preparations like documenting the consent to participate in the procedure or the filming for training purposes.

    Completion: Post-Operative Patient Care Plan (N1000)

    • This section details the post-operative care plan, focusing on recording vital signs, intake/output, level of consciousness, and pain management.
    • Essential parameters to track the overall condition of the patient.

    Completion: Implementation Record (N1009)

    • This record focuses on documenting all care activities performed for patients.
    • Timing, actions, observations, potential problems, and abnormalities should be recorded in detail.

    Completion: Prescription Chart (P1002)

    • Explain steps for completing prescription charts with patient allergies, weight, height, medical condition, and ward/bed information to be recorded.

    Completion: Pharmacy Order Form

    • This section deals with medication ordering for the pharmacy. This includes details like the date, time, medication name, amount, initial and signature of the employee in charge.

    Completion: Prescription Booklet (P3246)

    • This section details recording patient medication specifics, including allergies, risk factors, weight, height/BMI, ward/bed number, and date commencing.

    Completion: Clinical Evaluation: General Patients (CL3187)

    • The document is used to share patient care details with case managers for accurate claims and payments.
    • Shows a method of recording vital signs and other important patient information.

    History and Version Control

    • Details about the versions, effective dates, authors, and updates to ensure the policy remains current and applicable.

    Responsibilities

    • The document outlines specific responsibilities for unit managers, nurses, clinical facilitators, and learning/development facilitators in maintaining accurate documentation procedures.

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    Related Documents

    Patient Documentation Guideline V4 PDF

    Description

    Test your knowledge on the essential aspects of nursing documentation. This quiz covers recording practices, required entries, and the legal implications of patient documentation. Understand the importance of accurate records in ensuring quality care and compliance.

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