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15. A home health nurse is preparing for an initial home visit. Which information should be
included in the patient’s home care medical record?
a. Nursing process form
b. Step-by-step skills manual
c. A list of possible procedures
d. Reports to third-party payers
ANS: D
Information in the home care medical record includes patient assessment, referral and intake
forms, interprofessional plan of care, a list of medications, and reports to third-party payers.
An interprofessional plan of care is used rather than a nursing process form. A step-by-step
skills manual and a list of possible procedures are not included in the record.

DIF:Understand (comprehension) OBJ:Explain the guidelines for quality documentation.

TOP:Planning MSC: Management of Care

16. A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing
standardized protocols for assessment and care planning for reimbursement. Which task is the
nurse completing?
a. A minimum data set
b. An admission assessment and acuity level
c. A focused assessment/specific body system
d. An intake assessment form and auditing phase

ANS: A
The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS)
and the Care Area Assessment (CAA), is the data set that is federally mandated for use in
long-term care facilities by CMS. MDS assessment forms are completed upon admission, and
then periodically, within specific guidelines and time frames for all residents in certified
nursing homes. The MDS also determines the reimbursement level under the prospective
payment system. A focused assessment is limited to a specific body system. An admission
assessment and acuity level is performed in the hospital. An intake form is for home health.
There is no such thing as an auditing phase in an assessment intake.

DIF:Understand (comprehension) OBJ:Explain the guidelines for quality documentation.

TOP:Communication and Documentation MSC: Management of Care

17. A nurse is charting. Which event is critical for the nurse to document?
a. The patient had a good day with no complaints.
b. The family is demanding and argumentative.
c. The patient received a pain medication.
d. The family is poor and had to go on welfare.
ANS: C
Nursing interventions and treatments (e.g., medication administration) must be documented.
Avoid using generalized, empty phrases such as ―status unchanged‖ or ―had good day.‖ Do
not document retaliatory or critical comments about a patient, like demanding and
argumentative. Family is poor is not critical information to chart.

DIF:Apply (application) OBJ:Explain the guidelines for quality documentation.

TOP:Communication and Documentation MSC: Basic Care and Comfort

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18. A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a
patient. The nurse works in which area of patient care?
a. Home health
b. Intensive care unit
c. Skilled nursing facility
d. Long-term care facility
ANS: A
Nurses use two different data sets to document the clinical assessments and care provided in
the home care setting, the Outcome and Assessment Information Set (OASIS), and the Omaha
System. The intensive care unit does not use the OASIS data set. The long-term health care
setting includes skilled nursing facilities (SNFs) in which patients receive 24-hour day care.

DIF:Understand (comprehension) OBJ:Explain the guidelines for quality documentation.

TOP:Communication and Documentation MSC: Management of Care

19. A nurse is preparing to document a patient who has reported chest pain. Which information
provided by the patient is critical for the nurse to include?
a. ―My family doesn’t believe I’m in pain.‖
b. Pupils equal and reactive to light.
c. Had poor results from the pain medication.
d. Reports sharp pain of 8 on a scale of 1 to 10.
ANS: D
You need to ensure the information within a recorded entry or a report is complete, containing
appropriate and essential information (pain of 8). Document subjective and objective
assessment. While pupils equal and reactive to light is data, it does not relate to the chest pain;
this information would be critical for a head injury. Derogatory or inappropriate comments
about the patient or family is not appropriate. This kind of language can be used as evidence
for nonprofessional behavior or poor quality of care. Avoid using generalized, empty phrases
like ―poor results.‖ Use complete, concise descriptions.

DIF:Apply (application) OBJ:Discuss legal guidelines for documentation.

TOP:Communication and Documentation MSC: Basic Care and Comfort

20. Which action will the nurse take when taking a telephone order?
a. Print out a copy of the order once entered into the electronic health record.
b. Read back the order as written to the health care provider for verification.
c. Ask that another registered nurse listen to the call over an extension line.
d. Verify that the health care provider will write the order within 24 hours.
ANS: B
A read back of a telephone order is required and should contain all pertinent information so
that verification can be secured. None of the other options provide verification of the details
related to the order itself.

DIF:Apply (application) OBJ:Discuss legal guidelines for documentation.

TOP:Communication and Documentation MSC: Management of Care

21. A nurse obtained a telephone order from a primary care provider for a patient in pain. Which
chart entry should the nurse document?

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a. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr.
Day/J. Winds, RN, read back.
b. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J.
Winds, RN, read back.
c. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr.
Day/J. Winds, RN, read back.
d. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J.
Winds, RN.
ANS: C
The nurse receiving a TO or VO enters the complete order into the computer using the
computerized provider order entry (CPOE) software or writes it out on a physician’s order
sheet for entry in the computer as soon as possible. After you have taken the order, read the
order back, using the ―read back‖ process, and document that you did this to provide evidence
that the information received (such as call back instructions and/or therapeutic orders) was
verified with the provider. An example follows: “10/16/2015 (08:15), Change IV fluid to
Lactated Ringers with Potassium 20 mEq/L to run at 125 mL/hr. TO: Dr. Knight/J. Woods,
RN, read back.” VO stands for verbal order, not telephone order. The health care provider’s
name and read back must be included in the chart entry.

DIF:Apply (application)
OBJ:Select the elements to include in documentation of telephone conversations with providers.
TOP:Communication and Documentation MSC: Management of Care

22. A nurse is teaching the staff about informatics. Which information from the staff indicates the
nurse needs to follow up?
a. To be proficient in informatics, a nurse should be able to discover, retrieve, and
use information in practice.
b. A nurse needs to know how to find, evaluate, and use information effectively.
c. If a nurse has computer competency, the nurse is competent in informatics.
d. Nursing informatics is a recognized specialty area of nursing practice.
ANS: C
When the staff make an incorrect statement, then the nurse needs to follow up. Competence in
informatics is not the same as computer competency. All the rest are correct information, so
the nurse does not need to follow up. To become competent in informatics, you need to be
able to use evolving methods of discovering, retrieving, and using information in practice.
This means that you learn to recognize when information is needed and have the skills to find,
evaluate, and use that information effectively. Nursing informatics is a specialty that
integrates the use of information and computer technology to support all aspects of nursing
practice, including direct delivery of care, administration, education, and research.

DIF:Analyze (analysis)
OBJ:Discuss the relationship between informatics and quality health care.
TOP:Teaching/Learning MSC: Management of Care

23. A hospital is using a computer system that allows all health care providers to use a protocol
system to document the care they provide. Which type of system/design will the nurse be
using?
a. Clinical decision support system
b. Nursing process design

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c. Critical pathway design

d. Computerized provider order entry system

ANS: C
One design model for Nursing Clinical Information Systems (NCIS) is the protocol or critical
pathway design. This design facilitates interdisciplinary management of information because
all health care providers use evidence-based protocols or critical pathways to document the
care they provide. The knowledge base within a CDSS contains rules and logic statements that
link information required for clinical decisions in order to generate tailored recommendations
for individual patients, which are presented to nurses as alerts, warnings, or other information
for consideration. The nursing process design is the most traditional design for an NCIS. This
design organizes documentation within well-established formats such as admission and
postoperative assessments, problem lists, care plans, discharge planning instructions, and
intervention lists or notes. Computerized provider order entry (CPOE) systems allow health
care providers to directly enter orders for patient care into the hospital’s information system.

DIF:Understand (comprehension)
OBJ:Discuss the relationship between informatics and quality health care.
TOP:Communication and Documentation MSC: Management of Care

24. A nurse wants to reduce data entry errors on the computer system. Which action should the
nurse take?
a. Use the same password all the time.
b. Share password with only one other staff member.
c. Print out and review computer nursing notes at home.
d. Chart on the computer immediately after care is provided.
ANS: D
To increase accuracy and decrease unnecessary duplication, many health care agencies keep
records or computers near a patient’s bedside to facilitate immediate documentation of
information as it is collected. A good system requires frequent, random changes in personal
passwords to prevent unauthorized persons from tampering with records. When using a health
care agency computer system, it is essential that you do not share your computer password
with anyone under any circumstances. You destroy all papers containing personal information
immediately after you use them. Taking nursing notes home is a violation of the Health
Insurance Portability and Accountability Act (HIPAA) and confidentiality.

DIF:Apply (application) OBJ:Explain the guidelines for quality documentation.

TOP:Implementation MSC: Management of Care

25. Which entry will require follow-up by the nurse manager?

0800 Patient states, ―Fell out of bed.‖ Patient found lying by bed on the floor. Legs equal in
length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no
bruising or bleeding. Neuro checks within normal limits. States, ―Did not pass out.‖ Assisted
back to bed. Nurse call system within reach. Bed monitor on. —Jane More, RN
0810 Notified primary care provider of patient’s status. New orders received. —Jane More,
RN
0815 Portable x-ray of L hip taken in room. States, ―I feel fine.‖ —Jane More, RN
0830 Incident report completed and placed on chart. —Jane More, RN
a. 0800
b. 0810

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c. 0815
d. 0830

ANS: D
Do not include any reference to an incident in the medical record; therefore, the nurse
manager must follow up. A notation about an incident report in a patient’s medical record
makes it easier for a lawyer to argue that the reference makes the incident report part of the
medical record and therefore subject to attorney review. When an incident occurs, document
an objective description of what happened, what you observed, and the follow-up actions
taken, including notification of the patient’s health care provider in the patient’s medical
record. Remember to evaluate and document the patient’s response to the incident.

DIF:Analyze (analysis) OBJ:Discuss legal guidelines for documentation.

TOP:Communication and Documentation MSC: Management of Care

26. A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with
financial reimbursement?
a. Used incentive spirometer to encourage coughing and deep breathing. Lung
congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%.
Oxygen per nasal cannula applied at 2 L/min per standing order.
b. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated,
―felt better.‖ Finally, patient had no complaints.
c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
d. Status unchanged. Remains stable with no abnormal findings. Checked every 2
hours.
ANS: A
Accurately documenting services provided, including the supplies and equipment used in a
patient’s care, clarifies the type of treatment a patient received. This documentation also
supports accurate and timely reimbursement to a health care agency and/or patient. None of
the other options had equipment or supplies listed. Avoid using generalized, empty phrases
such as ―status unchanged‖ or ―had good day.‖ Do not enter personal opinions—stating that
the patient is cooperative is a personal opinion and should be avoided. ―Finally, patient had no
complaints‖ is a critical comment about the patient and if charted can be used as evidence of
nonprofessional behavior or poor quality of care.

DIF:Analyze (analysis)
OBJ:Compare the relationship between documentation and financial reimbursement for health care.
TOP:Communication and Documentation MSC: Management of Care

27. A nurse is teaching the staff about health care reimbursement. Which information should the
nurse include in the teaching session?
a. Home health, long-term care, and hospital nurses’ documentation can affect
reimbursement for health care.
b. A clinical information system must be installed by 2014 to obtain health care
reimbursement.
c. A ―near miss‖ helps determine reimbursement issues for health care.
d. HIPAA is the basis for establishing reimbursement for health care.
ANS: A

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