Documentation and Informatics Assignment
6. Which of the following charting entries is most accurate?
1. Patient walked up and down hallway with assistance,
2. Patient up, out of bed, walked down hallway and back to
room, tolerated well.
3. Patient up, walked 50 feet and back down hallway with
assistance from nurse. Spouse also accompanied patient
during the walk.
4. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and
regular following exercise.
7. Match the correct entry with the appropriate SOAP
1. S a. Repositioned patient on right side. Encouraged
patient to use patient-controlled analgesia (PCA)
2. O b. “The pain increases every time I try to turn on my
3. A c. Acute pain related to tissue injury from surgical
4. P d. Left lower abdominal surgical incision, 3 inches in
length, closed, sutures intact, no drainage. Pain
noted on mild palpation.
8. On the nursing unit you are able to access a patient’s medical
record and review the education that other nurses provided to
the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in
what type of record system?
1. Information technology.
2. Electronic health record.
3. Personal health information.
4. Administrative information system.
9. You are giving a hand-off report to another nurse who will be
caring for your patient at the end of your shift. Which of the
following pieces of information do you include in the report?
(Select all that apply.)
1. The patient’s name, age, and admitting diagnosis
2. Allergies to food and medications
3. Your evaluation that the patient is “needy”
4. How much the patient ate for breakfast
5. That the patient’s pain rating went from 8 to 2 on a scale
of 1 to 10 after receiving 650 mg of Tylenol
10. You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires
you to intervene? The nursing student:
1. Documented medication given by another nursing
2. Included the date and time of all entries in the chart.
3. Stood with his back against the wall while documenting on
4. Signed all documentation electronically.
11. A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major
advantage of using CPOE?
1. “CPOE reduces transcription errors.”
2. “CPOE reduces the time necessary for health care providers
to write orders.”
3. “Health care providers can write orders from any computer
that has Internet access.”
4. “CPOE reduces the time nurses use to communicate with
health care providers.
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