Chapter 3 Documentation and Medical Terminology

1. Medical records are legal documents. True or False.

2. Patients cannot view their medical records. True or False

3. All health records are confidential. True or False.

4. Charting by exception (CBE) uses more detailed flow sheets, which reduces the time
needed to chart and is quicker than narrative. True or False

5. The Kardex is a card-filing system used by nurses to condense all the orders and other
care information needed quickly for each patient. It is kept at the nursing station for
quick reference and is updated frequently. True or False

6. A patient with an acuity level of 3 requires less care than a patient with acuity of 5.
True or False

7. Confidentiality is a concern with computerized documentation. True or False

8. A good rule to follow is to document everything on all the assigned patients at the end
of the shift to make better use of time. True or False

9. Four o’clock in the afternoon is 1800 in military time. True or False

10. QD is an approved abbreviation for daily. True or False

11. An incident report should be completed if a visitor to the facility sustains injuries in a
fall. True or False

12. The combining form hepat/o refers to the liver. True or False

13. The suffix -penia means lack or deficiency. True or False

14. The doctor that specializes in diseases of the renal system is a nephrologist.
True or False

15. The abbreviations U or u for unit are on the “Do Not Use” list. True or False

16. Explain the parts of ISBARR communication.

17. Which orders are appropriately written? (Select all that apply.)
a. Glargine insulin 10 U SQ QD.
b. Weigh client every other day.
c. Digoxin 250 mcg PO daily.
d. MSO4 10 mg PO q 4 hours prn pain
e. Vitamin D 5000 IU PO every day.

18. Which statements are true regarding documentation? (Select all that apply.)
a. When using charting by exceptions, abnormal findings are charted in
narrative format.
b. An advantage of computer documentation is the expense to the facility,
c. The medical facility or health care provider is the owner of the clients’
medical records.
d. If a nurse forgets to document client care, legally it is considered not done.
e. Charting interventions in advance is encouraged so nothing gets missed.

19. Which statements are true regarding incident reports? (Select all that apply.)
a. When an incident report is completed, a brief note should be documented
in the progress notes stating it has been done.
b. An incident report should be completed with any medication errors.
c. When completing an incident report, the nurse needs to be concise and
document the facts of the incident.
d. The incident report becomes a part of the client’s legal record.
e. Incident reports can help identify standards of care/policies that may need
to be changed.

20. Which statements regarding terminology are correct? (Select all that apply.)
a. The root work for gland is aden/o.
b. Phlebitis means inflammation of the vein.
c. Cyt/o is the root word for bladder.
d. The abbreviation for an echocardiogram is ECG.
e. Myopathy translates to disease or condition of muscle.