NF 7 Documentation of Nursing Care

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Questions and Answers

Which type of charting shows the use of the nursing process and provides data for quality-assurance studies?

Protocols (PRŌ-tō-kŏlz)

Face sheet

Source-oriented (narrative) charting

Problem-oriented medical record (POMR) charting (correct)

What is the purpose of documentation in the medical record?

To communicate what has been done and how the patient responded (correct)

To determine the procedures performed and diagnoses established

To determine the actual length of stay

To provide data for quality-assurance studies

Which organization sets the standards for documentation?

Health care providers

The Joint Commission (correct)

Medicare

Insurance companies

Which form in a patient's medical record includes nursing diagnoses, goals and expected outcomes, and nursing interventions?

Nursing care plan Signup and view all the answers

Which of the following is a disadvantage of source-oriented (narrative) charting?

All of the above Signup and view all the answers

What is the primary purpose of a discharge summary?

To provide a plan for care after discharge Signup and view all the answers

What is the SOAP format used for in progress notes?

All of the above Signup and view all the answers

What is the acronym for the modified SOAP format used in the POMR charting method?

SOAPIE Signup and view all the answers

Which of the following is NOT a purpose of documentation in the medical record?

To calculate charges due for reimbursement Signup and view all the answers

What is the purpose of a preoperative checklist?

To verify that the patient is ready for surgery Signup and view all the answers

Where in the medical record would evaluation data be documented?

In the nurse's notes Signup and view all the answers

What is the role of documentation in the health care agency's quality-improvement program?

To provide evidence of care adhering to accepted standards Signup and view all the answers

Which of the following is a method of documentation used in various health care agencies?

Source-oriented charting Signup and view all the answers

What happens to the medical record after a patient is discharged?

It is sent to the medical records or health information department for safekeeping Signup and view all the answers

How long can a medical record be retrieved if the patient is admitted to service again?

Within a 10-year span Signup and view all the answers

How long can electronic records be kept for?

Indefinitely Signup and view all the answers

Which of the following is NOT a purpose of documentation (charting)?

Maintaining confidentiality and privacy of medical records Signup and view all the answers

Which method of documentation involves documenting only significant findings or exceptions to the norm?

Charting by exception Signup and view all the answers

What is the term for the electronic system that stores a patient's health information and can be accessed by authorized healthcare providers?

Electronic health record (EHR) Signup and view all the answers

What are the legal guidelines for documenting on medical records?

All of the above Signup and view all the answers

Which method of documentation focuses on patients and their problems, promotes a problem-solving approach to care, and improves continuity of care and communication?

POMR method Signup and view all the answers

Which method of documentation does not use a traditional nursing care plan, but instead uses nursing diagnoses and places the plan of care within the nurses' progress notes?

PIE charting Signup and view all the answers

Which method of documentation substitutes focus for the problem and is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event?

Focus charting Signup and view all the answers

What is the advantage of focus charting?

It is compatible with the use of the nursing process. Signup and view all the answers

Which documentation system was developed in the early 1980s by a group of nurses in Wisconsin?

Charting by Exception Signup and view all the answers

What is the assumption behind the charting by exception system?

All standards of practice are carried out and met with a normal or expected response unless otherwise documented. Signup and view all the answers

What is the goal of charting by exception?

To reduce repetition of data in traditional documentation systems. Signup and view all the answers

What are the heart of the charting by exception system?

Standard procedures and standards of nursing care Signup and view all the answers

What does charting by exception assume about undocumented actions?

If it wasn't documented, it wasn't done. Signup and view all the answers

What does the nurse need to document in the charting by exception system?

All abnormal findings or responses Signup and view all the answers

Which of the following is NOT a purpose of documentation in the medical record?

To track the application of the nursing process Signup and view all the answers

What is the primary purpose of a preoperative checklist?

To verify that the patient is ready to go to surgery Signup and view all the answers

Where in the medical record would evaluation data be documented?

Nurse's notes Signup and view all the answers

What does charting by exception assume about undocumented actions?

That they were not performed Signup and view all the answers

Which method of documentation focuses on deviations from predefined norms, using preset protocols and standards of care?

Charting by exception Signup and view all the answers

What is the primary purpose of a discharge summary?

To summarize the patient's stay and provide instructions for follow-up care Signup and view all the answers

What is the assumption behind the charting by exception system?

Only significant findings or exceptions to the norm are documented Signup and view all the answers

Which organization sets the standards for documentation?

American Nurses Association Signup and view all the answers

Which of the following is NOT a method of documentation discussed in this chapter?

Narrative charting Signup and view all the answers

What is the term for the electronic system that stores a patient's health information and can be accessed by authorized healthcare providers?

Electronic health record (EHR) Signup and view all the answers

Which of the following is a legal guideline for documenting on medical records?

Sign all entries with your full name and title Signup and view all the answers

Which method of documentation substitutes focus for the problem and is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event?

PIE charting Signup and view all the answers

Which type of charting shows the use of the nursing process and provides data for quality-assurance studies?

Problem-oriented medical record (POMR) charting Signup and view all the answers

What is the purpose of a preoperative checklist?

To record the patient's medical history and physical examination findings Signup and view all the answers

Which method of documentation substitutes focus for the problem and is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event?

Problem-oriented medical record (POMR) charting Signup and view all the answers

Which form in a patient's medical record includes nursing diagnoses, goals and expected outcomes, and nursing interventions?

Nursing care plan Signup and view all the answers

Which method of documentation uses the acronym SOAP and requires narrative documentation of assessment data?

SOAPIE charting Signup and view all the answers

What is the disadvantage of the POMR method of documentation?

Loss of chronologic documentation Signup and view all the answers

What is the acronym for the modified SOAP format used in the POMR charting method?

POMR Signup and view all the answers

What is the advantage of focus charting?

All of the above Signup and view all the answers

Which method of documentation focuses on patient status and emphasizes the problem-solving approach to patient care?

Problem-oriented medical record (POMR) charting Signup and view all the answers

What are the five basic parts of a Problem-oriented medical record (POMR)?

Database, problem list, plan, progress notes, discharge summary Signup and view all the answers

Which method of documentation encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information?

Source-oriented charting Signup and view all the answers

What is the advantage of the Problem-oriented medical record (POMR) charting method?

It gives information on the patient's condition and care in chronological order. Signup and view all the answers

Which of the following is the primary goal of charting by exception?

To document abnormal findings or responses correlated with nursing diagnoses Signup and view all the answers

What is the assumption behind the charting by exception system?

All standards of practice are carried out and met with a normal or expected response Signup and view all the answers

What are the heart of the charting by exception system?

Standard procedures Signup and view all the answers

Which of the following is NOT a purpose of charting/documentation?

To document abnormal findings or responses Signup and view all the answers

Which method of documentation involves documenting only significant findings or exceptions to the norm?

Charting by exception Signup and view all the answers

What is the purpose of documentation in the health care agency's quality-improvement program?

To provide data for quality-assurance studies Signup and view all the answers

Study Notes

Documentation of Nursing Care

Documentation in nursing provides a written record of the history, treatment, care, and response of the patient.
It serves multiple purposes, including justifying claims for reimbursement, serving as evidence in a court of law, and providing data for quality-assurance studies.
The medical record is a communication tool for the professionals involved in patient care.
Different forms are used for documentation, such as face sheets, provider orders, nursing care plans, nursing notes, and medication administration records.
The Joint Commission sets the standards for documentation in healthcare.
Documentation is used to determine the actual length of stay, procedures performed, and diagnoses established for insurance companies and Medicare.
The medical record is a legal record and can be used as evidence of events or treatment given.
Documentation is an essential part of the nursing process and is used to track the application of the nursing process.
The nursing care plan or interdisciplinary care plan provides the framework for nursing documentation.
Nursing diagnoses or problems are entered on the care plan, and interventions and patient responses are documented.
Evaluation data must be documented to show progress toward expected outcomes before a nursing diagnosis is marked as resolved.
Documentation in the medical record is audited as part of the health care agency's quality-improvement program.

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Test your knowledge about the importance and purposes of documentation in nursing care, including its use for reimbursement claims, legal evidence, and quality assurance. Explore different forms of nursing documentation and the standards set by the Joint Commission.

NF 7 Documentation of Nursing Care

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Podcast

Questions and Answers

Which type of charting shows the use of the nursing process and provides data for quality-assurance studies?

What is the purpose of documentation in the medical record?

Which organization sets the standards for documentation?

Which form in a patient's medical record includes nursing diagnoses, goals and expected outcomes, and nursing interventions?

Which of the following is a disadvantage of source-oriented (narrative) charting?

What is the primary purpose of a discharge summary?

What is the SOAP format used for in progress notes?

What is the acronym for the modified SOAP format used in the POMR charting method?

Which of the following is NOT a purpose of documentation in the medical record?

What is the purpose of a preoperative checklist?

Where in the medical record would evaluation data be documented?

What is the role of documentation in the health care agency's quality-improvement program?

Which of the following is a method of documentation used in various health care agencies?

What happens to the medical record after a patient is discharged?

How long can a medical record be retrieved if the patient is admitted to service again?

How long can electronic records be kept for?

Which of the following is NOT a purpose of documentation (charting)?

Which method of documentation involves documenting only significant findings or exceptions to the norm?

What is the term for the electronic system that stores a patient's health information and can be accessed by authorized healthcare providers?

What are the legal guidelines for documenting on medical records?

Which method of documentation focuses on patients and their problems, promotes a problem-solving approach to care, and improves continuity of care and communication?

Which method of documentation does not use a traditional nursing care plan, but instead uses nursing diagnoses and places the plan of care within the nurses' progress notes?

Which method of documentation substitutes focus for the problem and is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event?

What is the advantage of focus charting?

Which documentation system was developed in the early 1980s by a group of nurses in Wisconsin?

What is the assumption behind the charting by exception system?

What is the goal of charting by exception?

What are the heart of the charting by exception system?

What does charting by exception assume about undocumented actions?

What does the nurse need to document in the charting by exception system?

Which of the following is NOT a purpose of documentation in the medical record?

What is the primary purpose of a preoperative checklist?

Where in the medical record would evaluation data be documented?

What does charting by exception assume about undocumented actions?

Which method of documentation focuses on deviations from predefined norms, using preset protocols and standards of care?

What is the primary purpose of a discharge summary?

What is the assumption behind the charting by exception system?

Which organization sets the standards for documentation?

Which of the following is NOT a method of documentation discussed in this chapter?

What is the term for the electronic system that stores a patient's health information and can be accessed by authorized healthcare providers?

Which of the following is a legal guideline for documenting on medical records?

Which method of documentation substitutes focus for the problem and is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event?

Which type of charting shows the use of the nursing process and provides data for quality-assurance studies?

What is the purpose of a preoperative checklist?

Which method of documentation substitutes focus for the problem and is directed at a nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event?

Which form in a patient's medical record includes nursing diagnoses, goals and expected outcomes, and nursing interventions?

Which method of documentation uses the acronym SOAP and requires narrative documentation of assessment data?

What is the disadvantage of the POMR method of documentation?

What is the acronym for the modified SOAP format used in the POMR charting method?

What is the advantage of focus charting?

Which method of documentation focuses on patient status and emphasizes the problem-solving approach to patient care?

What are the five basic parts of a Problem-oriented medical record (POMR)?

Which method of documentation encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information?

What is the advantage of the Problem-oriented medical record (POMR) charting method?

Which of the following is the primary goal of charting by exception?

What is the assumption behind the charting by exception system?

What are the heart of the charting by exception system?

Which of the following is NOT a purpose of charting/documentation?

Which method of documentation involves documenting only significant findings or exceptions to the norm?

What is the purpose of documentation in the health care agency's quality-improvement program?

Study Notes

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