FREE UNAR Understanding Medical Documentation Questions and Answers

Question 1

______ is not in the process of adding valuable written information to a healthcare record.

Accepted Answer

Data entry

Answer

Recording

Answer

Charting

Answer

Documenting

Question 2

This is the main basis for cost reimbursement rates by government plans.

Accepted Answer

Diagnosis related groups

Answer

Patient expense documentation

Answer

Critical pathway

Answer

Minimum datasheet

Question 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.

Accepted Answer

Narrative

Answer

Kardex

Answer

Nurse's Notes

Answer

Shift report

Question 4

_________ is a traditional charting?

Accepted Answer

Narrative

Answer

Problem-Oriented Medical Record

Answer

SOAPE

Answer

DARE

Question 5

The right difference between PIE and SOAPE formats is

Accepted Answer

SOAPE is from a medical model, whereas PIE is from the nursing process.

Answer

PIE is part of a medical model, and SOAPE is not.

Answer

Both are same

Answer

PIE is a part of SOAPE.