SHADOW HEALTH SUBJECTIVE OBJECTIVE
DATA COLLECTION & DOCUMENTATION
STUDY GUIDE 2026
◉ As the nurse enters a patient's room, the nurse notices that the
patient is anxious. The patient quickly states, "I don't know what's
going on; I can't get an explanation from my doctor about my test
results. I want something done about this." Which of the following is
the most appropriate way for the nurse to document this
observation of the patient?
1. "The patient has a defiant attitude and is demanding test results."
2. "The patient appears to be upset with the nurse because he wants
his test results immediately."
3. "The patient is demanding and is complaining about the doctor."
4. "The patient stated feelings of frustration from the lack of
information received regarding test results.". Answer: 4
◉ The nurse is reviewing the Health Insurance Portability and
Accountability Act (HIPAA) regulations with the patient during the
admission process. The patient states, "I'm not familiar with these
HIPAA regulations. How will they affect my care?" Which of the
following is the best response?
, 1. HIPAA allows all hospital staff access to your medical record.
2. HIPAA limits the information that is documented in your medical
record.
3. HIPAA provides you with greater protection of your personal
health information.
4. HIPAA enables health care institutions to release all of your
personal information to improve continuity of care.. Answer: 3
◉ A patient states, "I would like to see what is written in my medical
record." What is the nurse's best response?
1. "Only your family can read your medical record."
2. "You have the right to read your record."
3. "Patients are not allowed to read their records."
4. "Only health care workers have access to patient records.".
Answer: 2
◉ Which of the following documentation entries is most accurate?
1. "Patient walked up and down hallway with assistance, tolerated
well."
2. "Patient up, out of bed, walked down hallway and back to room,
tolerated well."
DATA COLLECTION & DOCUMENTATION
STUDY GUIDE 2026
◉ As the nurse enters a patient's room, the nurse notices that the
patient is anxious. The patient quickly states, "I don't know what's
going on; I can't get an explanation from my doctor about my test
results. I want something done about this." Which of the following is
the most appropriate way for the nurse to document this
observation of the patient?
1. "The patient has a defiant attitude and is demanding test results."
2. "The patient appears to be upset with the nurse because he wants
his test results immediately."
3. "The patient is demanding and is complaining about the doctor."
4. "The patient stated feelings of frustration from the lack of
information received regarding test results.". Answer: 4
◉ The nurse is reviewing the Health Insurance Portability and
Accountability Act (HIPAA) regulations with the patient during the
admission process. The patient states, "I'm not familiar with these
HIPAA regulations. How will they affect my care?" Which of the
following is the best response?
, 1. HIPAA allows all hospital staff access to your medical record.
2. HIPAA limits the information that is documented in your medical
record.
3. HIPAA provides you with greater protection of your personal
health information.
4. HIPAA enables health care institutions to release all of your
personal information to improve continuity of care.. Answer: 3
◉ A patient states, "I would like to see what is written in my medical
record." What is the nurse's best response?
1. "Only your family can read your medical record."
2. "You have the right to read your record."
3. "Patients are not allowed to read their records."
4. "Only health care workers have access to patient records.".
Answer: 2
◉ Which of the following documentation entries is most accurate?
1. "Patient walked up and down hallway with assistance, tolerated
well."
2. "Patient up, out of bed, walked down hallway and back to room,
tolerated well."
