Nursing Documentation Quiz
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Welcome to the Nursing Documentation Quiz! This quiz tests your knowledge of essential practices in nursing documentation. Accurate and comprehensive documentation is crucial for patient care, communication among healthcare professionals, and legal purposes. Assess your understanding of proper charting, confidentiality, and record-keeping principles. Whether you're a seasoned nurse or a student, this quiz covers key aspects to enhance your documentation skills. Challenge yourself with scenarios and questions that reflect real-world situations, ensuring you're well-equipped to maintain precise and thorough records in the dynamic field of nursing. Good luck.
- 1.
______ is not in the process of adding valuable written information to a healthcare record.
- A.
Recording
- B.
Charting
- C.
Data entry
- D.
Documenting
Correct Answer
C. Data entryExplanation
“Data entry” generally refers to the act of inputting data into a system or database, but it doesn’t necessarily imply that the data being entered is valuable or meaningful in the context of a healthcare record. Therefore, the correct answer is C.Rate this question:
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- 2.
This is the main basis for cost reimbursement rates by government plans.
- A.
Patient expense documentation
- B.
Critical pathway
- C.
Minimum datasheet
- D.
Diagnosis related groups
Correct Answer
D. Diagnosis related groupsExplanation
Diagnoses Related Groups (DRGs) serve as the main basis for cost reimbursement rates by government plans. DRGs are a system used in healthcare to categorize hospital cases into groups based on similar clinical conditions and procedures. This classification system is crucial for determining the appropriate reimbursement rates for healthcare services provided.Rate this question:
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- 3.
What kind of documentation is the following? 0800-1300 0 45, pain scale 0/10, hand and leg, strong to the right, weak to the left. Skin pink, warm and dry, turgor good, incision to Rt. Anterior chest wall erythema or edema ...................Jane Night, LPN.
- A.
Kardex
- B.
Narrative
- C.
Nurse's Notes
- D.
Shift report
Correct Answer
B. NarrativeExplanation
The answer is, "Narrative" because the documentation provided appears to be a detailed account of a patient’s condition, including vital signs, pain scale, physical assessment, and the nurse’s observations. This type of detailed, chronological account is typically found in Nurse’s Notes. Nurse’s Notes are used to document a patient’s condition and the care that has been given, including the administration of drugs, the performance of procedures, and the patient’s response to treatment.Rate this question:
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- 4.
_________ is a traditional charting?
- A.
Narrative
- B.
Problem-Oriented Medical Record
- C.
SOAPE
- D.
DARE
Correct Answer
A. NarrativeExplanation
Traditional charting methods often involve a narrative format, where healthcare professionals document patient information in a free-text paragraph style. In narrative charting, events and observations are recorded in a chronological order, providing a comprehensive overview of the patient's condition and care.Rate this question:
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- 5.
The right difference between PIE and SOAPE formats is
- A.
SOAPE is from a medical model, whereas PIE is from the nursing process.
- B.
PIE is part of a medical model, and SOAPE is not.
- C.
Both are same
- D.
PIE is a part of SOAPE.
Correct Answer
A. SOAPE is from a medical model, whereas PIE is from the nursing process.Explanation
In summary, the key difference between the PIE (Problem, Intervention, Evaluation) and SOAPE (Subjective, Objective, Assessment, Plan, and sometimes Education) documentation formats lies in their conceptual origins. SOAPE is derived from a medical model, often used in medical and healthcare settings, while PIE is rooted in the nursing process, emphasizing the nurse's role in identifying problems, planning and implementing interventions, and evaluating outcomes. This distinction reflects the underlying approaches to patient care and documentation in medical and nursing contexts, respectively.Rate this question:
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- 6.
When does discharge planning ideally begin?
- A.
During admission
- B.
After admission
- C.
Before admission
- D.
Without admission
Correct Answer
A. During admissionExplanation
Discharge planning is a process that aims to ensure a smooth transition from hospital to home or another facility. Ideally, discharge planning should begin during admission. This allows healthcare providers to understand the patient’s needs and plan for appropriate care and resources after discharge.Rate this question:
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Current Version
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Aug 30, 2024Quiz Edited by
ProProfs Editorial Team
Expert Reviewed by
Ives Holganza -
Apr 28, 2013Quiz Created by
Arnoldjr2