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Exam 5: Documentation

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Question 1

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The staff members at a hospital are preparing for a visit from The Joint Commission (TJC) .Which should be explained to the staff about the purpose of this visit? Select all that apply.

A) TJC acts as an insurance company by offering reimbursement to hospitals.
B) TJC seeks to improve the safety and quality of care that health-care organizations provide to the public.
C) TJC offers accreditation when a facility practices in a manner that meets TJC standards.
D) TJC sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance.
E) TJC sets the standards by which the quality of health care is managed nationally and internationally.

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Question 2

Multiple Choice

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The nursing instructor is asked to prepare an educational program on incidents that have occurred on a specific care area.Which is the most cost-effective approach for the instructor to collect information to support the educational program?

A) Complete a database search through the electronic medical record.
B) Meet with risk management to review incident reports for the care area.
C) Ask the nurse manager to provide specific data regarding client incidents.
D) Access a quality assurance website to obtain information about common incidents.

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A

Question 3

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The nurse uses a cheat sheet to jot down pertinent client data while providing care.What should the nurse do with the sheet after documenting all client care?

The nurse completes documentation on an electronic medical record.What should the nurse do next?

A hospital's risk-management team provides the nursing staff with an in-service about incident reports.Which information should be included? Select all that apply.

The nurse discovers a client lying on the floor.Which should the nurse write when completing an incident report?

While documenting in a client's chart, the nurse realizes that it is the wrong chart.What should the nurse do?

The nursing instructor is reviewing documentation with a group of students.Which should the instructor include as the purpose of written documentation? Select all that apply.

The director of a home care agency is scheduling staff to make home visits.Which staff member should visit a client newly admitted to the agency for care?

Information about the Health Insurance Portability and Accountability Act (HIPAA) is being prepared for a group of new nurses to review during orientation.Which should be emphasized about this act? Select all that apply.

The nurse reviews pertinent laboratory data and assesses the response to pain medication.Where should the nurse write this information until able to document it in the medical record?

A health-care facility uses narrative charting.What should the nurse remember when following this documentation approach?

The nurse is preparing to document care provided in the client's electronic medical record.Which should the nurse keep in mind when entering the data?

The nursing instructor is reviewing the different types of charting methods with the class.Which should the instructor explain for the acronym SOAPIER?

The nurse receives a login and password to access the electronic medical record.Where should the nurse store this information?

A resident is being admitted to the skilled nursing facility.Which documentation is required to be completed for this client?

A health-care organization is considering focus charting.Which categories are commonly documented using this approach?

A client received a dose of intravenous pain medication before change of shift.After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest.Who is most liable for this situation?

The nursing instructor teaches students about source-oriented medical records.Which labeled tabs should the instructor emphasize? Select all that apply.

The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client.Where should the nurse locate this information?