Documentation and Communication Flashcards
7 cards from real LVN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Communication flashcards as text
When documenting a patient's pain using the SOAP format, where would you record the patient's verbal report of pain severity?
Answer: Subjective
Subjective data includes information reported by the patient, such as their verbal description of pain.
An LVN notes 'Pt. ambulated to BR without assistance' in the chart. Which documentation principle does this reflect?
Answer: Use of approved abbreviations and factual language
Documentation should use approved abbreviations and factual, observable language rather than interpretation.
A physician's written order is illegible. What is the most appropriate action for the LVN?
Answer: Call the physician to clarify the order before proceeding
The LVN must contact the prescriber directly to clarify any illegible or unclear orders before carrying them out.
Which of the following is an example of objective data to document in a patient's chart?
Answer: Blood pressure 148/92 mmHg
Objective data is measurable and observable; a specific blood pressure reading is a clear example.
The LVN made a documentation error in a paper chart. What is the correct way to correct it?
Answer: Draw a single line through the error, write 'error,' initial, and date it
The correct method is a single line through the error with 'error,' the nurse's initials, and date — never obliterate original entries.
When using military time in documentation, which correctly represents 9:45 PM?
Answer: 2145
Military time adds 12 hours to PM times: 9 PM + 12 = 21, so 9:45 PM = 2145.
A patient refuses a prescribed medication. How should the LVN document this?
Answer: Document 'refused' with the reason stated by the patient and notify the charge nurse
Medication refusals must be documented with the patient's stated reason, and the charge nurse and physician should be notified.