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
An LVN witnesses a patient fall in the hallway. After ensuring patient safety, what is the NEXT priority documentation action?
Answer: File an incident/occurrence report and document in the chart separately
An incident report (occurrence report) must be filed separately from the chart, and the event is also documented in the nursing notes.
During change-of-shift report, which information is most critical for the oncoming nurse to receive?
Answer: Current vital signs, significant changes, and pending orders
Change-of-shift report must include current clinical status, significant changes, and any pending or new orders to ensure continuity of care.
A physician gives the LVN a verbal order over the phone. What is the correct procedure?
Answer: Write the order, read it back to the physician for confirmation, then carry it out
Verbal orders require a read-back verification to confirm accuracy before implementation, then must be signed by the physician within facility-defined timeframes.
The SBAR communication tool stands for which of the following?
Answer: Situation, Background, Assessment, Recommendation
SBAR stands for Situation, Background, Assessment, Recommendation — a structured format for clinical handoffs and escalations.
Which entry demonstrates appropriate late-entry documentation in a patient's chart?
Answer: Writing 'Late Entry' with the current date/time and the time the event occurred
Late entries must be labeled 'Late Entry' with the actual time of writing and the original time of the event to maintain accuracy.
An LVN notices a pattern of a patient's blood pressure readings trending upward over several shifts. The most appropriate communication action is to:
Answer: Notify the charge nurse and document the trend and notification
Trending vital signs that may indicate deterioration must be reported promptly to the charge nurse, with documentation of the pattern and the communication.
Which of the following is NOT appropriate to include in an incident report?
Answer: Opinion about whose fault the incident was
Incident reports should contain factual information only — opinions, blame, or assumptions about fault are inappropriate and potentially harmful.