FA Davis CH 17; Documenting and
Reporting Exam Actual Questions and
Answers 2026
Which type of organization of health records involves members of
each discipline recording their findings in a separate section of the
chart?
A. Source-oriented
B. Problem-oriented
C. Charting by exception
D. Improvement-oriented -
correct answer ✅A
In source-oriented record systems, members of each discipline
record their findings in separate sections of the chart.
Which are ways health providers use documentation to provide
quality care? Select all that apply.
A. Communication tool
B. Continuity of care
C. Provide shift report
D. Communicate with family members
E. Legal record -
correct answer ✅A,B,E
, FA Davis CH 17; Documenting and
Reporting Exam Actual Questions and
Answers 2026
Which represents correct documentation in the medical record of
an initial nursing assessment of a client admitted with pneumonia?
1. the client appears short of breath, with wheezing in all lung fields
2. the client is admitted with pneumonia and the nurse will watch
for respiratory systems
3. respiratory treatments are given as ordered every 4 hours
4. the client reports improved breathing after breathing treatments
given -
correct answer ✅A
What should be considered when using abbreviations in nursing
documentation?
A. It is acceptable to use common abbreviations in all
documentation.
B. Abbreviations should never be used in documentation.
C. Each facility should have a list of approved abbreviations, and
those that should not be used.
D. Every medical record should have a reference as an addendum to
identify the meaning of any abbreviations. -
correct answer ✅C
Reporting Exam Actual Questions and
Answers 2026
Which type of organization of health records involves members of
each discipline recording their findings in a separate section of the
chart?
A. Source-oriented
B. Problem-oriented
C. Charting by exception
D. Improvement-oriented -
correct answer ✅A
In source-oriented record systems, members of each discipline
record their findings in separate sections of the chart.
Which are ways health providers use documentation to provide
quality care? Select all that apply.
A. Communication tool
B. Continuity of care
C. Provide shift report
D. Communicate with family members
E. Legal record -
correct answer ✅A,B,E
, FA Davis CH 17; Documenting and
Reporting Exam Actual Questions and
Answers 2026
Which represents correct documentation in the medical record of
an initial nursing assessment of a client admitted with pneumonia?
1. the client appears short of breath, with wheezing in all lung fields
2. the client is admitted with pneumonia and the nurse will watch
for respiratory systems
3. respiratory treatments are given as ordered every 4 hours
4. the client reports improved breathing after breathing treatments
given -
correct answer ✅A
What should be considered when using abbreviations in nursing
documentation?
A. It is acceptable to use common abbreviations in all
documentation.
B. Abbreviations should never be used in documentation.
C. Each facility should have a list of approved abbreviations, and
those that should not be used.
D. Every medical record should have a reference as an addendum to
identify the meaning of any abbreviations. -
correct answer ✅C
