Nursing Documentation Quiz
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1. This is the main basis for cost reimbursement rates by government plans.
- A. Critical pathway
- B. Minimum datasheet
- C. Diagnoses related groups
- D. Patient expense documentation
2. 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
3. _________ is a traditional charting?
- A. Narrative
- B. Problem-Oriented Medical Record
- C. SOAPE
- D. DARE
4. 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.
5. When does discharge planning ideally begin?
- A. During admission
- B. After admission
- C. Before admission
- D. Without admission
6. ______ is not in the process of adding written valuable information for a health care record?
- A. Recording
- B. Charting
- C. Data entry
- D. Documenting
