DEWITS FUNDAMENTAL CONCEPTS AND
SKILLS FOR NURSING ACTUAL
EXAMINATION TEST PAPER 2026
QUESTIONS AND SOLUTIONS
◉ The medical record is the property of who or what?
Answer: The healthcare facility or agency
◉ What are the six main methods of documentation
Answer: 1. Source-oriented (narrative) charting
2. problem-oriented medical record (POMR) charting
3. focus charting
4. charting by exception
5. computer assisted charting
6. case management system charting
◉ SOAP stands for what?
Answer: Subjective data, Objective data, Assessment data, and Plan
◉ What does the "IER" stand for in SOAPIER
Answer: Implementation, Evaluation, and Revision
, ◉ PIE stands for what?
Answer: Problem identification, Interventions, and Evaluation
◉ Focus charting has what three components
Answer: Data, Action, Response (DAR) or Data, Action, and
Evaluation (DAE)
◉ Charting by exception is based on what assumption?
Answer: That all standards of practice are carried out and met with a
normal or expected response unless otherwise documented.
◉ It is important to have a standard what for the entire
interdisciplinary team?
Answer: Terminology
◉ What is a major concern when using an electronic documentation
system?
Answer: Confidentiality
◉ What should you never do while a patient's medical record is on
the computer screen?
Answer: Leave the terminal
SKILLS FOR NURSING ACTUAL
EXAMINATION TEST PAPER 2026
QUESTIONS AND SOLUTIONS
◉ The medical record is the property of who or what?
Answer: The healthcare facility or agency
◉ What are the six main methods of documentation
Answer: 1. Source-oriented (narrative) charting
2. problem-oriented medical record (POMR) charting
3. focus charting
4. charting by exception
5. computer assisted charting
6. case management system charting
◉ SOAP stands for what?
Answer: Subjective data, Objective data, Assessment data, and Plan
◉ What does the "IER" stand for in SOAPIER
Answer: Implementation, Evaluation, and Revision
, ◉ PIE stands for what?
Answer: Problem identification, Interventions, and Evaluation
◉ Focus charting has what three components
Answer: Data, Action, Response (DAR) or Data, Action, and
Evaluation (DAE)
◉ Charting by exception is based on what assumption?
Answer: That all standards of practice are carried out and met with a
normal or expected response unless otherwise documented.
◉ It is important to have a standard what for the entire
interdisciplinary team?
Answer: Terminology
◉ What is a major concern when using an electronic documentation
system?
Answer: Confidentiality
◉ What should you never do while a patient's medical record is on
the computer screen?
Answer: Leave the terminal
