Module 3

Question 0

What are the four main purposes of documentation?

Answer 0

1. Communication with other staff
2. Reimbursement
3. Establishes a legal record of the patient’s status and care given
   (legal)
4. Used to provide data for nursing research

Question 1

What does capital SBAR stand for?

Answer 1

Situation - The situation you are calling about
Background - pertinent background information related to the situation
(mental status, etc.)
Assessment - what is the nurses assessment of the situation? (what
you found/think)
Recommendation - what is the nurses recommendation or what does
the nurse want?

Question 2

What patient information is confidential?

Answer 2

All information about patients written on paper, spoken out loud, saved on the computer