CARDIOVASCULAR DOCUMENTATION
STUDY GUIDE 2026 ACTUAL QUESTIONS
WITH SOLUTIONS GRADED A+
● What does the phrase 'not charted, not done' imply? Answer: If
something is not documented, it is assumed that it was not performed.
● What is the property status of a medical record? Answer: The medical
record is the property of the hospital or facility, but the information
belongs to the patient.
● What rights does HIPAA grant patients regarding their medical
records? Answer: Patients have the right to view and obtain a copy of
their medical record.
● What must a patient do before their medical records can be shared
with another physician? Answer: The patient must sign a written
consent.
● What is confidentiality in the context of nursing documentation?
Answer: The maintenance of privacy by not sharing privileged
information with unauthorized individuals.
STUDY GUIDE 2026 ACTUAL QUESTIONS
WITH SOLUTIONS GRADED A+
● What does the phrase 'not charted, not done' imply? Answer: If
something is not documented, it is assumed that it was not performed.
● What is the property status of a medical record? Answer: The medical
record is the property of the hospital or facility, but the information
belongs to the patient.
● What rights does HIPAA grant patients regarding their medical
records? Answer: Patients have the right to view and obtain a copy of
their medical record.
● What must a patient do before their medical records can be shared
with another physician? Answer: The patient must sign a written
consent.
● What is confidentiality in the context of nursing documentation?
Answer: The maintenance of privacy by not sharing privileged
information with unauthorized individuals.
