Records and reports, types and its uses, preparation and maintenance.
What is the primary legal purpose of a patient's medical record?
[a] To provide a source of data for medical research.
[b] To serve as the primary tool for communication between healthcare providers.
[c] To provide proof of the quality of care delivered and protect against litigation.
[d] To act as a basis for billing and reimbursement from insurance companies.
A nurse gives a verbal summary of her assigned patients' conditions to the nurse coming on for the next shift. This is an example of a:
[a] Record
[b] Legal document
[c] Census
[d] Report
Which of the following is an example of an administrative record maintained on a nursing unit?
[a] A patient's care plan
[b] An incident report
[c] A doctor's progress notes
[d] The daily patient census sheet
When a nurse discovers that a patient has fallen out of bed, she must complete a specific document. This document is known as a(n):
[a] Incident report
[b] Patient's chart
[c] Kardex
[d] Discharge summary
A key principle of effective documentation is to be timely. This means the nurse should document care:
[a] At the end of the shift to ensure all information is included.
[b] The day after the care was provided.
[c] As soon as possible after the care or event occurs.
[d] Whenever there is a spare moment during the shift.
Which statement is the best example of factual, objective documentation?
[a] "Patient seems angry and uncooperative this morning."
[b] "Patient had a good night and slept well."
[c] "Patient's wound on left calf is 3 cm in length with reddened edges and a small amount of yellow drainage."
[d] "Patient appears to be in a lot of pain."
If a nurse makes an error while documenting on a paper record, the correct action is to:
[a] Use correction fluid (white-out) to cover the error.
[b] Black out the entire entry with a marker.
[c] Erase the entry and rewrite it correctly.
[d] Draw a single line through the error, write "error" or "mistaken entry", and initial it.
The primary ethical principle that governs the maintenance and use of all patient records is:
[a] Beneficence
[b] Justice
[c] Confidentiality
[d] Veracity
How are patient records used for Quality Assurance (QA) or Continuous Quality Improvement (CQI)?
[a] To ensure every nurse has the same handwriting.
[b] Through audits to identify patterns, trends, and adherence to standards of care.
[c] To calculate the total cost of care for each patient.
[d] By allowing patients to read their own charts and provide feedback.
A Kardex or patient care summary is a type of record that:
[a] Is a permanent legal part of the medical record.
[b] Contains detailed information about the patient's financial status.
[c] Provides a quick, up-to-date summary of current care needs for daily use by the nursing team.
[d] Is only filled out upon the patient's discharge.
What is a major advantage of an Electronic Health Record (EHR) compared to a traditional paper record?
[a] It is less expensive to implement and maintain.
[b] It eliminates the risk of data breaches.
[c] It allows for simultaneous access by multiple users and improves legibility.
[d] It does not require any training for staff to use.
A key nursing responsibility when using an EHR is to:
[a] Share your password with colleagues who have forgotten theirs.
[b] Stay logged in to a computer workstation for the entire shift for efficiency.
[c] Use a simple, easy-to-remember password like "1234".
[d] Protect your login information and always log off when leaving the computer.
The saying "If it wasn't documented, it wasn't done" highlights the importance of records as a(n):
[a] Educational tool
[b] Legal account of care provided
[c] Research database
[d] Communication method
The proper method for destroying paper records containing protected health information is:
[a] Tearing them into a few pieces.
[b] Throwing them in the regular trash bin.
[c] Shredding or burning them in an approved manner.
[d] Storing them indefinitely in a locked cabinet.
In community health nursing, a family folder is a type of record that:
[a] Contains only the health information of the mother.
[b] Consolidates the health information of all members of a single family.
[c] Is used only for families with communicable diseases.
[d] Is a temporary record and is discarded after each visit.
Why is it essential for a nurse to sign and date every entry made in a patient's record?
[a] To show that they have the neatest handwriting.
[b] To make it easier for the patient to identify them.
[c] To practice their signature for legal documents.
[d] To demonstrate accountability and responsibility for the entry.
Which type of report is used to track the number of patients on a unit, including admissions, discharges, and transfers?
[a] Incident report
[b] Anecdotal report
[c] Census report
[d] Research report
Why do healthcare facilities often have a "Do Not Use" list for abbreviations?
[a] To make documentation more difficult for nurses.
[b] To encourage nurses to write out full sentences.
[c] To prevent dangerous errors from misinterpretation of similar abbreviations.
[d] To comply with international spelling standards.
A referral summary report is prepared when a patient is transferred to another facility. What is its main purpose?
[a] To provide a final bill to the patient.
[b] To ensure continuity of care by communicating the patient's current status and care plan.
[c] To inform the original facility's administration of the transfer.
[d] To get feedback from the new facility on the quality of care provided.
Who legally owns the physical patient record (the paper chart or electronic file)?
[a] The patient
[b] The patient's primary physician
[c] The government
[d] The healthcare institution or facility
An anecdotal record is a personal, handwritten note about an event. What is the best practice regarding these types of records?
[a] They should be used as the primary source of patient documentation.
[b] They should be filed directly into the patient's official chart.
[c] They are for personal use and should not be part of the official record, though facts should be documented formally.
[d] They should be shared with the patient and their family.
When documenting a patient's refusal of a medication, the nurse should:
[a] Omit any mention of the medication to avoid legal issues.
[b] Document that the medication was given to maintain the schedule.
[c] Only tell the next shift nurse but not write it down.
[d] Document the refusal, the reason given by the patient, and that the physician was notified.
The use of records and reports for education primarily involves:
[a] Serving as case studies and learning tools for students and new staff.
[b] Teaching patients how to document their own health.
[c] Providing materials for public health campaigns.
[d] Educating administrators about hospital finances.
In charting by exception (CBE), what does the nurse document?
[a] A detailed head-to-toe assessment every hour.
[b] Only the care that was provided according to the plan.
[c] Only significant findings or deviations from the established norms or standards.
[d] A summary of all conversations held with the patient's family.
Long-term storage and maintenance policies for medical records are primarily dictated by:
[a] The preference of the individual nurse.
[b] The amount of available storage space in the facility.
[c] The patient's request for how long their records should be kept.
[d] State and federal laws and institutional policies.
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