PRACTICAL NURSING THEORY EXAM REVIEW | COMPLETE LPN/LVN STUDY
GUIDE, PRACTICE QUESTIONS & EXAM PREP 2026/2027
What is Health Care Documentation? - ANS ✔✔any written or electronically generated
information about a patient that describes:
-patient's history
-patient's current health status
-care, treatments & services provided
-discussions with the patient and/or significant others
-date & time and the health care professional's signature and status
Purpose of Health Care Documentation? - ANS ✔✔facilitation of information flow to support
continuity, quality, and safety of care
Goal of Health Care Documentation? - ANS ✔✔to describe facts clearly and concisely to
improve communication
What is a Health Care Record? - ANS ✔✔•Contains comprehensive patient info.
•Communication tool; promotes continuity of care
•Single data access point for staff
•Legal document (can be used by lawyers, judges)
•Clinical data archive for: a coroner's investigation, insurance company, CNO
•Tool for research, audits, quality control, education, performance appraisals
in Ontario, documentation must comply with - ANS ✔✔CNO's Professional and Practice
Standards
,A Health Carre record provides legal evidence of care: permanent record therefore must be -
ANS ✔✔-clear and concise
-accurate, complete and objective
-timely
-accessible
-must not be altered or have spelling or grammar errors
What kind of time is used in documentation? - ANS ✔✔Military time
Potential Problems with a Written Record - ANS ✔✔-If black ink is not used, may not fax or
photocopy well
-Spaces can be left
-Can be difficult to locate
-Single-user access
-Fragile, susceptible to damage, can degrade
-Handwriting may be illegible
-Storage can be problematic
Potential Problems with an Electronic Record - ANS ✔✔-Initial cost (purchasing, setting
up/connecting, training staff)
-Sharing of passwords
EMR stands for - ANS ✔✔(electronic medical record)
EMR = - ANS ✔✔a record of one episode of care
EHR stands for - ANS ✔✔electronic health record
,EHR = - ANS ✔✔longitudinal record of health (includes in-pt. and out-pt. documentation)
What is the CNA vision? - ANS ✔✔by 2020 every Canadian will have a secure, portable and
accessible electronic health record
What can Electronic Documentation do? - ANS ✔✔•permits Computerized Provider Order Entry
(CPOE)
•can offer decision support and guideline-based care
•enhances communication
•provides long term cost savings
•provides security mechanisms (to prevent outside hackers, network damage, and theft or
misuse of info)
•increases productivity
•allows multiple simultaneous users
•decrease errors and storage space issues•supports administrative processes
•ensures frequent changes and strong passwords (comb. of letters, numbers and/or symbols)
•allows for electronic signatures
Common Parts of a Health Care Record - ANS ✔✔•patient identification and demographic data
•informed consent fro treatment and procedures
•advance directives
•medical hx and progress notes; consult notes from specialists
•doctors' orders
•nursing data base (e.g., admission assessment, nurses notes, graphic sheet, fluid balance
sheet, bowel record, skin & falls assess., IV record)
•reports of diagnostic studies•operative record
, •discharge plan and summary
Confidentiality and Privacy - ANS ✔✔•Nurses have a professional and legal obligation to protect
patient information
•written releases needed to share info. from the chart
•shred worksheets once no longer needed
Patient information: - ANS ✔✔must be safeguarded-** only shared with individuals who have a
need and a right to know
Right to privacy = - ANS ✔✔the right to be free from intrusion or disturbance in private life
Abbreviations - ANS ✔✔•nurses must be aware of the danger of using abbreviations that may
be misunderstood and compromise patient safety
•document using only accepted abbreviations and acronymsto facilitate effective
communication among care providers that supports safe patient care
Accuracy in Charting - ANS ✔✔•be factual, professional, non-judgemental
** do not use general, vague, ambiguous or slang terms such as: 'seems', 'appears' ,
'apparently' 'small' or 'large', 'usual day', 'good night', 'nice man', 'difficult patient'
•use exact quotes: patient stated "go to hell".
•every entry must have: date, time, full signature and your correct title/status
•with written documentation: use black ink, do not erase or white-out errors, no blank spaces,
be legible
•chart only care that you have provided
Electronic documentation: do not share your password•never name another pt: instead use
'patient's room-mate'
•pt ID on each page (sticker; addressograph)
GUIDE, PRACTICE QUESTIONS & EXAM PREP 2026/2027
What is Health Care Documentation? - ANS ✔✔any written or electronically generated
information about a patient that describes:
-patient's history
-patient's current health status
-care, treatments & services provided
-discussions with the patient and/or significant others
-date & time and the health care professional's signature and status
Purpose of Health Care Documentation? - ANS ✔✔facilitation of information flow to support
continuity, quality, and safety of care
Goal of Health Care Documentation? - ANS ✔✔to describe facts clearly and concisely to
improve communication
What is a Health Care Record? - ANS ✔✔•Contains comprehensive patient info.
•Communication tool; promotes continuity of care
•Single data access point for staff
•Legal document (can be used by lawyers, judges)
•Clinical data archive for: a coroner's investigation, insurance company, CNO
•Tool for research, audits, quality control, education, performance appraisals
in Ontario, documentation must comply with - ANS ✔✔CNO's Professional and Practice
Standards
,A Health Carre record provides legal evidence of care: permanent record therefore must be -
ANS ✔✔-clear and concise
-accurate, complete and objective
-timely
-accessible
-must not be altered or have spelling or grammar errors
What kind of time is used in documentation? - ANS ✔✔Military time
Potential Problems with a Written Record - ANS ✔✔-If black ink is not used, may not fax or
photocopy well
-Spaces can be left
-Can be difficult to locate
-Single-user access
-Fragile, susceptible to damage, can degrade
-Handwriting may be illegible
-Storage can be problematic
Potential Problems with an Electronic Record - ANS ✔✔-Initial cost (purchasing, setting
up/connecting, training staff)
-Sharing of passwords
EMR stands for - ANS ✔✔(electronic medical record)
EMR = - ANS ✔✔a record of one episode of care
EHR stands for - ANS ✔✔electronic health record
,EHR = - ANS ✔✔longitudinal record of health (includes in-pt. and out-pt. documentation)
What is the CNA vision? - ANS ✔✔by 2020 every Canadian will have a secure, portable and
accessible electronic health record
What can Electronic Documentation do? - ANS ✔✔•permits Computerized Provider Order Entry
(CPOE)
•can offer decision support and guideline-based care
•enhances communication
•provides long term cost savings
•provides security mechanisms (to prevent outside hackers, network damage, and theft or
misuse of info)
•increases productivity
•allows multiple simultaneous users
•decrease errors and storage space issues•supports administrative processes
•ensures frequent changes and strong passwords (comb. of letters, numbers and/or symbols)
•allows for electronic signatures
Common Parts of a Health Care Record - ANS ✔✔•patient identification and demographic data
•informed consent fro treatment and procedures
•advance directives
•medical hx and progress notes; consult notes from specialists
•doctors' orders
•nursing data base (e.g., admission assessment, nurses notes, graphic sheet, fluid balance
sheet, bowel record, skin & falls assess., IV record)
•reports of diagnostic studies•operative record
, •discharge plan and summary
Confidentiality and Privacy - ANS ✔✔•Nurses have a professional and legal obligation to protect
patient information
•written releases needed to share info. from the chart
•shred worksheets once no longer needed
Patient information: - ANS ✔✔must be safeguarded-** only shared with individuals who have a
need and a right to know
Right to privacy = - ANS ✔✔the right to be free from intrusion or disturbance in private life
Abbreviations - ANS ✔✔•nurses must be aware of the danger of using abbreviations that may
be misunderstood and compromise patient safety
•document using only accepted abbreviations and acronymsto facilitate effective
communication among care providers that supports safe patient care
Accuracy in Charting - ANS ✔✔•be factual, professional, non-judgemental
** do not use general, vague, ambiguous or slang terms such as: 'seems', 'appears' ,
'apparently' 'small' or 'large', 'usual day', 'good night', 'nice man', 'difficult patient'
•use exact quotes: patient stated "go to hell".
•every entry must have: date, time, full signature and your correct title/status
•with written documentation: use black ink, do not erase or white-out errors, no blank spaces,
be legible
•chart only care that you have provided
Electronic documentation: do not share your password•never name another pt: instead use
'patient's room-mate'
•pt ID on each page (sticker; addressograph)
