In-Service Test

Purposes for documentation include:

There are many aspects to charting in addition to the progress notes.

The Health Insurance Portability and Accountability Act (HIPPA) allows nurses to give information to friends of a client unless otherwise instructed.

The nursing process – assessment, diagnosis, planning, implementation, and evaluation – is the basis of documentation.

Only approved abbreviations and symbols should be used in documenting.

Which is NOT true about documenting:

Errors in charting should be crossed out with a thick line so they cannot be read.

Physician orders should indicate if they are telephone or verbal orders.

Allergies and sensitivities should be listed on each page of the client’s clinical record.

No blank spaces should be left in progress notes.

Late entries should be written between the lines so the note is in chronological order.

If a nurse gives a client the wrong medication, he/she should immediately tell the client.

Nurse must initial in a MAR once administration of medication is completed.

In-service training is mandatory for all employees that want to continue working for Atlas Home Health, INC.

Each employee is given two choices for attendance in the in-service training on the 1^st and 15^th of every month.

It is not necessary to submit a two-week notice prior to quitting a particular client.

Badges must be worn at all times when coming to the office and visiting Atlas’ patients.

If you have signed up for an in-service training session and are not able to attend, you must notify the agency prior to the actual day of training.

Which time frame corresponds to April 1^st payroll date?

If an occurrence has occurred during your shift you must:

In order to receive payment for the services you have provided you must:

All the in-service monthly tests must be completed and returned to the office within

A resident falls on the evening shift. Staff witnessed the fall. The resident is assessed and no injury noted. The resident does not complain of pain. Staff does not document the fall and does not pass the information on to the next shift, which is contrary to facility policy. No increased monitoring is performed, as other staff members are unaware of the fall. For the next two days the resident complains of pain. After two days, the physician is notified and x-rays taken which confirm a fracture. Is this reportable is neglect?

Staff put a hot pack on a resident’s back. The hot pack was placed on the resident without sufficient padding between the hot pack and the skin. Staff was aware of what amount of padding should be used to prevent a burn. The resident had fragile skin due to her age. She sustained a partial thickness burn is this reportable as neglect?

A 72- year-old female hospice resident in a nursing home had a fall in her room. She hit her head on the nightstand and had a huge bruise. The resident was receiving comfort measures only. She became difficult to arouse the next morning, developed lapses of consciousness and had difficulty with speaking clearly. Is this reportable?

A 70-year-old male who had been up and around using walker, was very difficult to arouse in the morning. His speech was garbled. Is this reportable?