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VNPT51 CHAPTER 3 Documentation Q&A

The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse (LPN/LVN) regarding documentation. Which statement by the preceptor is correct? 1. It is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR).
The patient asks the LPN/LVN if he can take his chart with him on discharge from the hospital. Which response by the nurse is most accurate? 4. The chart is the property of the hospital, but if you need copies of your records, we can arrange that for you.
When reviewing information regarding the problem-oriented medical record (POMR), the LPN/LVN correctly identifies which guideline? 3. The charting format is SOAPE or SOAPIER.
The LPN/LVN is using the SOAPE method to chart. When documenting the S portion, which entry demonstrates correct documentation? 4. Patient ambulated 20 ft. unassisted with steady gait.
The student nurse is correct when identifying which concept regarding documentation as being correct? 1. Chart as soon and as often as necessary.
Understanding that health care personnel must respect the confidentiality of patient records, which action by the nurse is appropriate? 3. Reading charts only for a professional reason.
Following orientation to the facility's computer system, which statement by the new nurse is most accurate? 1. "I can save on charting time once I am comfortable using this system."
The nurse demonstrates knowledge of correctly completing an incident report with which action? 4. Documenting facts regarding the incident.
Which statement is correct about formats for documentation (select all that apply)? 3. Charting by exception documents those conditions, interventions, or outcomes outside the norm. 5. EHR systems allow for patient data to be shared for collaboration of care.
Which statement is a recommended guideline for charting? 4. The patient's name and identification number should be on all documents.
Which statement is a safe principle of computerized charting? 4. Do not leave patient information displayed on the monitor.
Which accreditation agency specifies guidelines for documentation? 1. The Joint Comission (TJC)
What is the primary purpose of Title II of the Health Insurance Portability and Accountability Act (HIPAA)? 2. Maintain privacy and confidentiality of patient's health information.
Which statement is correct about abbreviations? (select all that apply) 1. The nurse should be aware of any abbreviations on the "do not use" list . 4. When in doubt, the nurse should use the complete word and not the abbreviation.
The nurse documents in the patient record, " 0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and analgesic administered as ordered with adequate relief. J. Doe RN." 4. The documentation is unacceptable because it is vague nondescriptive data without supportive data.
Which statement best describes narrative documentation? 2. Documentation that describes occurrences in descriptive form.
In most states, patients can gain access to their medical records by which means? 2. Submitting a written request to the facility to view the record.
Standards and policies regarding documentation in long-term care facilities are guided by: 1. Minimum data sets (MDS)
The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on what prospective payment system? 4. Diagnosis-related groups (DRGs)
Created by: barragan_93230
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