CBT Practice Question 5

NMC defines record keeping as all of the following except:

• Helping to improve advocacy
• Showing how decisions related to patient care were made
• Supporting effective clinical judgements and decisions
• Helping in identifying risks, and enabling early detection of complications

When do we need to document?

• As soon as possible after an event has happened to provide current up to date information about the care and condition of the patient or client
• Every hour
• When there are significant changes to the patient’s condition
• At the end of the shift

All should be seen in a good documentation except:

• legible handwriting
• Name and signature, position, date and time
• Abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements
• A correct, consistent, and factual data

A nurse documented on the wrong chart. What should the nurse do?

• Immediately inform the nurse in charge and tell her to cross it all off.
• Throw away the page
• Write line above the writing; put your name, job title, date, and time.
• Ignore the incident.

After finding the patient which statement would be most appropriate for the nurse to document on a datix/incident form?

• “The patient climbed over the side rails and fell out of bed.”
• “The use of restraints would have prevented the fall.”
• “Upon entering the room, the patient was found lying on the floor.”
• “The use of a sedative would have helped keep the patient in bed.”

Information can be disclosed in all cases except:

• When effectively anonymized.
• When the information is required by law or under a court order.
• In identifiable form, when it is required for a specific purpose, with the individual’s written consent or with support under the Health
• In Child Protection proceedings if it is considered that the information required is in the public or child’s interest

Adequate record keeping for a medical device should provide evidence of:

• A unique identifier for the device, where appropriate
• A full history, including date of purchase and where appropriate when it was put into use, deployed or installed
• Any specific legal requirements and whether these have been met
• Proper installation and where it was deployed
• All the above

A registered nurse had a very busy day as her patient was sick, got intubated & had other life saving procedures. She documented all the events & by the end of the shift recognized that she had documented in other patient's record. What is best response of the nurse?

• She should continue documenting in the same file as the medical document cannot be corrected
• She should tear the page from the file & start documenting in the correct record
• She should put a straight cut over her documentation & write as wrong, sign it with her NMC code, date & time
• She should write as wrong documentation in a bracket & continue

Barbara, a frail lady who lives alone with her cat, was brought in A&E via ambulance after a neighbour found her lying in front of her house. No doctor is available to see her immediately. Barbara told you she is worried about her cat who is alone in the house. How will you best reply to her?

• You should worry about yourself and not the cat.”
• “Your cat sounded like very dear to you. Can I ask your neighbour to check?”
• “Do you want me to see you cat also? I cannot do that now.”
• “Your cat can look after itself, I am sure.”

What are essential competencies for today's nurse manager?

• strategic planning and design
• Self and group awareness
• A vision and goals
• Communication and teamwork