STRUCTURED QUESTIONNAIRE

Instructions
1) Answer all questions as honest as possible. 2) Please mark your answer in the bracket provided for multiple choice questions. 3) For question numbers 32 to 34 and 36, please provide your answer in one or two sentences in the provided space.

Your cooperation in filling out this questionnaire would be greatly appreciated. Please do not write your name on the questionnaire. Your confidentiality is assured.

Section A: Demographic data

1) Age in years a) b) c) d) 21-30 31-40 41-50 Above 50

( )

2) Sex a) Male b) Female 3) Professional education

( )

( )

a) b) c) d)

Multipurpose health worker General nurse midwifery B.Sc.nursing Masters in nursing

4) Designation a) b) c) d) e) Floor in charge Head Nurse Staff Nurse Senior Intern Junior Intern

( )

5) Total years of work experience a) b) c) d) e) 1-5 years 6-10 years 11-15 years 16-20 years Above 20 years

( )

6) Nurse patient ratio in the area of work a) b) c) d) 1:4 1:10 1:15 1:20

Section B: questions related to knowledge of nurses regarding documentation of patient care

1) What is documentation a) b) c) d) Oral communication Data of client Written, legal record of interactions with client Medical history of client

( c )

2) Primary purpose of documentation of client care is a) b) c) d) Communication among health care professionals Assurance Training of team members Response to illness

( a )

3) Client records serves as a) b) c) d) Legal document of client health status Quality care Cost effective method Quality assurance

( a )

4) Documentation must be consistent with a) b) c) d) Vital statistics Professional and agency standards Historical document Decision analysis

( b )

5) Nurses must utilize .. to communicate clearly and concisely ( d ) a) b) c) d) Standard medical terminology Nursing terminology Abbreviations Accepted standard terminology

6) Which provides an accurate and detailed account of treatment and care given to the client ( d ) a) b) c) d) observations Progress notes Physical examination Records & Reports ( b )

7) Records should be a) b) c) d) Brief, correct and critical Truthful, Brief and complete Complete and Brief Truthful and Complete

8) .. are the effective methods of communication among members of the health team ( a ) a) b) c) d) Records and Reports Charts Registers Procedures ( a)

9) Records are to be kept under a) b) c) d) Safe custody of nurses Safe custody of Doctor Safe custody of floor in charge Safe custody of Department head

10) a) b) c) d)

Records should be arranged

( b )

Alphabetically, Numerically, Geographically Alphabetically, Numerically with index card, Geographically Geographically and Alphabetically Alphabetically, Numerically with index card All Records are identified with the .of the clients. ( c )

11) a) b) c) d)

Diagnosis Bio data IP number Name

Section C: Questions related to the practice of nurses regarding documentation of patient care. 12) a) b) c) d) 13) a) b) c) d) How documentation should be done Precise Brief Critical In detail Which of the following can be used for writing documentation ( b ) Pencil Ball point pen Gel Pen Ink pen ( b )

14) ) a) b) c) d) 15) ) a) b) c) d) 16) ) a) b) c) d) 17) a) b) c) d) 18) a) b) c) d)

After 7 p.m. which type of ink should be used for documentation ( c

Green Blue Red Black In which chart do you mark the pulse rate ( a

TPR Chart Nurses Notes I/O Chart Drug Chart Where do you document the weight of the patient ( b

Nurses Notes TPR Chart Drug Chart I/O chart How many time per day do you check vital signs Q2H Q4H Q6H Q8H Blood transfusion is marked in which chart Nurses Notes TPR Chart Drug Chart I/O chart

(b )

19)

Will you write diagnosis on the TPR chart

a) Yes b) No 20) a) b) c) d) 21) a) b) c) d) 22) a) b) c) d) 23) a) b) c) d) Among the following which is the graphical chart Nurses Notes Drug Chart I/O chart TPR Chart Where do you document the drains of the patient Drug Chart GIK chart TPR chart I/O chart Where do you document the aspirated fluids TPR chart GIK chart I/O chart Drug Chart CVP is measured in mm of Hg cm of Hg mm of H20 cm of H20 ( c ) ( d )

( d )

( d )

24) Which action should the nurse take when a recording mistake has occurred (d ) a) b) c) d) Draw a line through the mistake Draw a line through it and write error above the entry Draw a line through it and write the mistake entry above it Draw a line through the mistake and write mistake entry and your initials above it. The nurses notes should address the clients progress in relation to the ( a )

25) .. a) b) c) d)

Outcomes of patient care Objectives of institution Client care Family care

Answer the following in one sentence 26) How do you document telephonic orders ? .. 27) List out the names of the registers maintained by staff nurses in the wards. .

28) Will the patient care documentation be reviewed during audits? .......................................

29)

Do you support the computerized patient care documentation (

a) Yes b) No 30) If your answer to the above question is NO, please state the reason. .