Documentation and Reporting Flashcards
7 cards from real RPN 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 Reporting flashcards as text
A nurse is documenting informed consent. Which element is NOT required as part of informed consent documentation?
Answer: The nurse's personal opinion on whether the patient should proceed
Informed consent documentation captures the patient's decision after receiving objective information; the nurse's personal opinion is not a required element.
Which of the following best describes 'charting by exception' (CBE)?
Answer: Only documenting findings that deviate from established norms or the care plan
Charting by exception documents only abnormal findings or deviations from the plan, assuming normal findings unless noted otherwise.
A nurse suspects a patient is experiencing elder abuse. Mandatory reporting laws require the nurse to report this to:
Answer: The appropriate adult protective services or designated agency as required by state law
Nurses are mandated reporters in all U.S. states and must report suspected elder abuse to adult protective services or the legally designated agency.
How long must most hospitals in the U.S. retain adult patient medical records according to federal regulations and accreditation standards?
Answer: At least 5 to 10 years (varies by state), or until the patient's 21st birthday if a minor
Medical record retention requirements vary by state but generally require retention for a minimum of 5–10 years for adults, with extended requirements for minors.
When a nurse documents 'patient tolerated procedure well' without supporting observations, this is an example of:
Answer: A vague, conclusory statement that lacks objective detail
Phrases like 'tolerated well' are conclusory and do not provide the objective data needed to support the statement or defend care if questioned.
Which of the following situations requires the nurse to make a mandatory report to the state board of nursing?
Answer: A nurse who is observed practicing while impaired by alcohol or drugs
Nurses are obligated to report colleagues who practice while impaired, as this poses a direct threat to patient safety and violates professional standards.
A nurse forgets to sign an entry in the paper medical record. The appropriate action is to:
Answer: Return to the entry, add a late signature with the date and time of signing
An unsigned entry can be corrected by returning to the note, adding a signature, and documenting the date and time the signature was added.
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