Inpatient Progress Note Quiz
Inpatient Progress Note Quiz
1. What is the primary purpose of a daily inpatient progress note?
a) To document billing codes only
b) To record the patient’s response to treatment and update the plan of care
c) To repeat the patient’s entire medical history
d) To summarize nursing care activities
2. In the Subjective section of the progress note, what type of information should you include?
a) Patient’s report of symptoms and relevant input from family or nursing staff
b) Your physical exam findings
c) Lab and diagnostic test results
d) Detailed past medical history
3. Which of the following belongs in the Objective section?
a) Patient’s description of pain
b) Vital signs, lab results, and physical exam findings
c) Your assessment of the patient’s condition
d) Plan for medication changes
4. Why is it important to choose specific ICD-10 diagnoses in the Assessment and Plan?
a) To accurately reflect the patient’s condition and support billing
b) To make notes longer and more detailed
c) To repeat information from the subjective section
d) To focus only on the primary diagnosis regardless of severity
5. What should you avoid in the Subjective section?
a) Patient’s direct quotes
b) Input from nursing staff
c) Your own interpretations and physical exam findings
d) Relevant family observations
6. When documenting quality and performance measures, what is the main goal?
a) To impress insurance companies
b) To support patient safety, regulatory compliance, and quality improvement
c) To make notes longer
d) To replace the Assessment and Plan section
7. What does Tip #5 (Organization and Precision) emphasize?
a) Writing very detailed narratives about every aspect of the patient’s history
b) Focusing on key clinical issues and keeping the daily plan clear and concise
c) Copying previous notes verbatim to save time
d) Including as much information as possible regardless of relevance
8. True or False: Including images like chest X-rays or EKG strips in the Objective section can enhance documentation quality.
9. Which statement best describes how NP students should approach progress note writing compared to RN documentation?
a) Write progress notes the same way as registered nurses
b) Include only pertinent data relevant to their service line and avoid excessive detail typical of nursing notes
c) Write mostly narrative notes without structured sections
d) Focus only on billing codes
10. What is one way to improve your progress note writing skills?
a) Practice regularly and review examples from your clinical service line
b) Avoid reading other providers’ notes
c) Write very short notes with minimal information
d) Skip the Assessment and Plan if busy
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