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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?
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?
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?
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?
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?
Which of the following is a disadvantage of source-oriented (narrative) charting?
What is the primary purpose of a discharge summary?
What is the primary purpose of a discharge summary?
What is the SOAP format used for in progress notes?
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?
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?
Which of the following is NOT a purpose of documentation in the medical record?
What is the purpose of a preoperative checklist?
What is the purpose of a preoperative checklist?
Where in the medical record would evaluation data be documented?
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?
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?
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?
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 a medical record be retrieved if the patient is admitted to service again?
How long can electronic records be kept for?
How long can electronic records be kept for?
Which of the following is NOT a purpose of documentation (charting)?
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?
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 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?
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 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 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?
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?
What is the advantage of focus charting?
Which documentation system was developed in the early 1980s by a group of nurses in Wisconsin?
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 assumption behind the charting by exception system?
What is the goal of charting by exception?
What is the goal of charting by exception?
What are the heart of the charting by exception system?
What are the heart of the charting by exception system?
What does charting by exception assume about undocumented actions?
What does charting by exception assume about undocumented actions?
What does the nurse need to document in the charting by exception system?
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?
Which of the following is NOT a purpose of documentation in the medical record?
What is the primary purpose of a preoperative checklist?
What is the primary purpose of a preoperative checklist?
Where in the medical record would evaluation data be documented?
Where in the medical record would evaluation data be documented?
What does charting by exception assume about undocumented actions?
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?
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 primary purpose of a discharge summary?
What is the assumption behind the charting by exception system?
What is the assumption behind the charting by exception system?
Which organization sets the standards for documentation?
Which organization sets the standards for documentation?
Which of the following is NOT a method of documentation discussed in this chapter?
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?
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 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 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?
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?
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 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 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?
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 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 acronym for the modified SOAP format used in the POMR charting method?
What is the advantage of focus charting?
What is the advantage of focus charting?
Which method of documentation focuses on patient status and emphasizes the problem-solving approach to patient care?
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)?
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?
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?
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?
Which of the following is the primary goal of charting by exception?
What is the assumption behind the charting by exception system?
What is the assumption behind the charting by exception system?
What are the heart of 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 of the following is NOT a purpose of charting/documentation?
Which method of documentation involves documenting only significant findings or exceptions to the norm?
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?
What is the purpose of documentation in the health care agency's quality-improvement program?
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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Description
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.
