LVN Documentation and Communication 2 — Questions and Answers
Question 1: When documenting a patient's pain using the SOAP format, where would you record the patient's verbal report of pain severity?
- Assessment
- Objective
- Subjective (Correct answer)
- Plan
Correct answer: Subjective
Subjective data includes information reported by the patient, such as their verbal description of pain.
Question 2: An LVN notes 'Pt. ambulated to BR without assistance' in the chart. Which documentation principle does this reflect?
- Use of approved abbreviations and factual language (Correct answer)
- Subjective interpretation of behavior
- Inference about patient intent
- Late entry charting technique
Correct answer: Use of approved abbreviations and factual language
Documentation should use approved abbreviations and factual, observable language rather than interpretation.
Question 3: A physician's written order is illegible. What is the most appropriate action for the LVN?
- Interpret the order based on context and carry it out
- Contact the pharmacy to interpret the order
- Call the physician to clarify the order before proceeding (Correct answer)
- Skip the order and document it as unreadable
Correct 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.
Question 4: Which of the following is an example of objective data to document in a patient's chart?
- Patient states 'I feel dizzy'
- Patient appears anxious
- Blood pressure 148/92 mmHg (Correct answer)
- Patient seems to be in pain
Correct answer: Blood pressure 148/92 mmHg
Objective data is measurable and observable; a specific blood pressure reading is a clear example.
Question 5: The LVN made a documentation error in a paper chart. What is the correct way to correct it?
- Use correction fluid (white-out) to cover the error
- Draw a single line through the error, write 'error,' initial, and date it (Correct answer)
- Erase the error completely and rewrite
- Tear out the page and rewrite the entry
Correct 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.
Question 6: When using military time in documentation, which correctly represents 9:45 PM?
- 0945
- 2145 (Correct answer)
- 2045
- 1945
Correct answer: 2145
Military time adds 12 hours to PM times: 9 PM + 12 = 21, so 9:45 PM = 2145.
Question 7: A patient refuses a prescribed medication. How should the LVN document this?
- Leave the medication administration record blank
- Document 'refused' with the reason stated by the patient and notify the charge nurse (Correct answer)
- Administer the medication anyway and document compliance
- Only notify the physician and skip charting the refusal
Correct 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.
LVN Documentation and Communication 2
When documenting a patient's pain using the SOAP format, where would you record the patient's verbal report of pain severity?