RPN Documentation and Reporting 5 — Questions and Answers
Question 1: A nurse is documenting informed consent. Which element is NOT required as part of informed consent documentation?
- The patient's signature confirming understanding
- A description of the procedure and its risks
- The nurse's personal opinion on whether the patient should proceed (Correct answer)
- Alternatives to the proposed treatment
Correct 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.
Question 2: Which of the following best describes 'charting by exception' (CBE)?
- Documenting every patient interaction in full narrative form
- Only documenting findings that deviate from established norms or the care plan (Correct answer)
- Charting after each shift rather than in real time
- Using only electronic systems for all documentation
Correct 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.
Question 3: A nurse suspects a patient is experiencing elder abuse. Mandatory reporting laws require the nurse to report this to:
- Only the attending physician
- The appropriate adult protective services or designated agency as required by state law (Correct answer)
- The patient's family members first
- The hospital's billing department
Correct 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.
Question 4: How long must most hospitals in the U.S. retain adult patient medical records according to federal regulations and accreditation standards?
- 1 year after discharge
- At least 5 to 10 years (varies by state), or until the patient's 21st birthday if a minor (Correct answer)
- Indefinitely, with no time limit
- 30 days after discharge
Correct 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.
Question 5: When a nurse documents 'patient tolerated procedure well' without supporting observations, this is an example of:
- Accurate and thorough documentation
- A vague, conclusory statement that lacks objective detail (Correct answer)
- Appropriate use of abbreviations
- Charting by exception
Correct 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.
Question 6: Which of the following situations requires the nurse to make a mandatory report to the state board of nursing?
- A colleague who frequently arrives five minutes late
- A nurse who is observed practicing while impaired by alcohol or drugs (Correct answer)
- A patient who complains about a physician's bedside manner
- A nurse who calls in sick more than once a month
Correct 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.
Question 7: A nurse forgets to sign an entry in the paper medical record. The appropriate action is to:
- Leave it unsigned since the handwriting is recognizable
- Return to the entry, add a late signature with the date and time of signing (Correct answer)
- Ask a supervisor to sign on the nurse's behalf
- Rewrite the entire entry on a new line with a signature
Correct 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.
RPN Documentation and Reporting 5
A nurse is documenting informed consent.
Which element is NOT required as part of informed consent documentation?