WGU D117 Advanced Health Assessment
Documentation Form
Comprehensive 105-Question Exam with Complete Solutions
Latest 2026/2027 Update | Graduate Nursing Education
Western Governors University (WGU) | D117 Advanced Health Assessment
Exam Overview: This comprehensive examination contains 105 multiple-choice questions distributed across nine sections
aligned with the WGU D117 Advanced Health Assessment Documentation Form competencies. The exam is designed to
evaluate graduate-level knowledge and application of advanced health assessment documentation principles, including
SOAP note structure, subjective and objective data collection, comprehensive physical examination by body system,
clinical reasoning, ICD-10 coding, and documentation form completion competency. Questions are weighted across
cognitive levels with approximately 30% recall, 50% application, and 20% analysis. Approximately 75% of questions are
scenario-based or application-based, reflecting real clinical documentation challenges, while 25% test direct recall of
documentation standards. Each question includes a detailed rationale explaining the correct answer, why the distractors are
incorrect, and the underlying documentation principles aligned with the WGU D117 rubric. This exam reflects current
2026-2027 documentation standards, ICD-10-CM coding updates, and WGU documentation form expectations.
Exam Structure at a Glance
Section Question Range Topic Area
1 Q1 - Q12 Documentation Fundamentals and Standards
2 Q13 - Q30 Subjective Data Collection
3 Q31 - Q40 Objective Data - General and Integumentary
4 Q41 - Q54 Objective Data - HEENT, Neck, and Respiratory
5 Q55 - Q66 Objective Data - Cardiovascular and Peripheral Vascular
6 Q67 - Q78 Objective Data - Abdomen and Musculoskeletal
7 Q79 - Q90 Objective Data - Neurological and Mental Health
8 Q91 - Q100 Assessment, Differential Diagnosis, and Plan
9 Q101 - Q105 Documentation Form Completion and Competency
TOTAL 105 Questions Comprehensive WGU D117 Competency Coverage
Instructions for Use: Each question presents four answer choices (A, B, C, D) with exactly one correct answer marked
[CORRECT]. The rationale below each question explains the documentation principle, differentiates correct from incorrect
options, and provides complete-solution guidance aligned with WGU D117 rubric expectations. Use this exam for
self-assessment, competency preparation, and review of advanced health assessment documentation standards.
Section 1: Documentation Fundamentals and Standards (SOAP Format,
Charting Standards, HIPAA, & Legal Documentation)
,Q1: A nurse practitioner is completing a SOAP note for a patient seen in an outpatient clinic. The patient
states, "My chest has been hurting for the past three days." In which section of the WGU D117 documentation
form should this statement be recorded?
A. Assessment, because it reflects the clinician's interpretation of the symptom
B. Objective, because chest pain is an observable finding
C. Subjective, because it is the patient's verbatim report of symptoms [CORRECT]
D. Plan, because it determines the diagnostic workup needed
Correct Answer: C
Rationale: The Subjective section of a SOAP note captures all data reported by the patient, including the chief complaint,
history of present illness, and associated symptoms. A verbatim patient statement such as chest pain is inherently subjective
because it cannot be independently measured by the examiner. Placing it in the Objective section violates SOAP structure, the
Assessment section requires clinical reasoning rather than raw data, and the Plan section addresses interventions rather than
patient-reported information. The WGU D117 rubric specifically evaluates whether subjective data are correctly segregated
from objective findings.
Q2: During a comprehensive encounter, the advanced practice nurse documents: "BP 138/86, HR 82, RR 16,
T 37.0°C, SpO2 98% on room air." Which section of the documentation form is the appropriate location for
these findings?
A. Subjective, because vital signs are reported by the patient
B. Objective, because vital signs are measurable data obtained by the clinician [CORRECT]
C. Assessment, because abnormal values must be interpreted
D. Plan, because vital signs guide clinical decisions
Correct Answer: B
Rationale: Vital signs are measurable, observable data obtained directly by the clinician through the use of instruments such
as a sphygmomanometer and thermometer; therefore they belong in the Objective section of the SOAP note. The Subjective
section is reserved for patient-reported information, while the Assessment section synthesizes data into diagnoses, and the
Plan outlines interventions. Documenting vital signs in any section other than Objective is a common D117 rubric deduction
because it violates the fundamental distinction between measured data and interpreted findings.
Q3: A graduate nursing student is preparing to fax a patient's health assessment documentation to a
specialist. Under the HIPAA minimum necessary standard, which action best demonstrates compliance?
A. Fax the entire medical record to ensure the specialist has complete context
B. Fax only the portions of the record relevant to the referral and the specialist's role [CORRECT]
C. Fax only the demographic sheet to protect patient privacy
D. Fax the documentation without a cover sheet to streamline the process
Correct Answer: B
Rationale: The HIPAA minimum necessary standard requires that protected health information disclosed for treatment,
payment, or operations be limited to the minimum needed to accomplish the intended purpose. Faxing only the relevant
portions respects patient privacy while supporting continuity of care. Sending the entire record over-discloses protected
information, sending only demographics is insufficient for clinical decision-making, and omitting a cover sheet fails to
identify the recipient, increasing the risk of misdirected disclosure. The WGU D117 form expects documentation of
HIPAA-compliant handling of patient information.
,Q4: An advanced practice nurse realizes, two days after a patient encounter, that an important finding was
omitted from the original documentation. Which is the correct method for adding a late entry to the electronic
health record?
A. Delete the original note and create a new one with the added information
B. Alter the original entry to include the missing information and change the timestamp
C. Create a new addendum labeled "Late Entry" with the current date, time, and reference to the original
encounter [CORRECT]
D. Verbally inform the next clinician and skip formal documentation
Correct Answer: C
Rationale: Late entries must be documented as addenda that include the current date and time of the addition, a clear reference
to the original encounter, and the label "Late Entry" or "Addendum." Altering or deleting the original note violates legal
documentation standards and constitutes falsification of the medical record. Verbal reporting alone is insufficient because
documentation must support continuity of care and withstand legal scrutiny. The D117 rubric evaluates adherence to charting
standards including appropriate handling of late entries and corrections.
Q5: Which of the following entries best distinguishes subjective data from objective data in a comprehensive
health assessment note?
A. "Patient appears diaphoretic and reports chest pressure rated 7/10." [CORRECT]
B. "Patient has chest pain and elevated blood pressure."
C. "Patient is sick and looks unwell."
D. "Patient was treated for hypertension and feels better."
Correct Answer: A
Rationale: Option A clearly separates subjective data ("reports chest pressure rated 7/10") from objective data ("appears
diaphoretic"), reflecting proper SOAP documentation principles. Option B conflates subjective and objective findings without
distinguishing which is which, Option C uses vague non-clinical terminology that would be marked down on the D117 rubric,
and Option D mixes intervention with outcome without clear categorization. Graduate-level documentation must use precise
medical terminology and explicitly delineate subjective from objective content.
Q6: According to current charting standards, documentation of a patient encounter should be completed
within what timeframe to meet timeliness requirements?
A. Within 30 days of the encounter
B. By the end of the same shift or as soon as possible after the encounter [CORRECT]
C. Within one week of the patient encounter
D. Only when the insurance company requests the record
Correct Answer: B
Rationale: Timeliness in documentation requires that entries be completed by the end of the same shift or as soon as possible
after the encounter to ensure accuracy, support continuity of care, and meet regulatory standards. Delaying documentation by
30 days or one week risks memory decay and inaccurate entries, and waiting for an insurer request violates the principle of
contemporaneous charting. The D117 documentation form evaluates whether students adhere to timeliness expectations
consistent with professional nursing standards and institutional policy.
, Q7: A graduate nursing student makes an error while documenting in a paper chart. Which is the correct
method for correcting the error?
A. Use correction fluid to cover the error and write the correct information
B. Erase the error completely and rewrite the entry
C. Draw a single line through the error, write "error," initial and date it, then write the correct entry
[CORRECT]
D. Black out the error with a marker so it cannot be read
Correct Answer: C
Rationale: The legally accepted method for correcting paper documentation errors is to draw a single line through the
incorrect entry, write "error" nearby, initial and date the correction, then document the accurate information. This preserves
the original entry for legal review and demonstrates transparency. Correction fluid, erasure, and blacking out are forbidden
because they obscure the original content and may be construed as falsification. The D117 rubric assesses knowledge of
legally compliant documentation practices.
Q8: Which of the following entries is most appropriately placed in the Plan section of the SOAP note?
A. "Patient has community-acquired pneumonia."
B. "Crackles auscultated in right lower lobe."
C. "Start azithromycin 500 mg PO daily x 5 days; recheck in 1 week." [CORRECT]
D. "Patient reports productive cough for 4 days."
Correct Answer: C
Rationale: The Plan section of a SOAP note contains the diagnostic, pharmacologic, educational, and follow-up interventions
chosen by the clinician. Prescribing azithromycin and scheduling follow-up are concrete actions that belong in the Plan.
Option A is an Assessment (diagnosis), Option B is an Objective finding, and Option D is Subjective data. Confusing
Assessment with Plan is one of the most common D117 rubric deductions and reflects inadequate clinical reasoning
documentation.
Q9: When documenting medical necessity for an advanced health assessment, which element must be
explicitly stated to justify the level of service billed?
A. The patient's insurance identification number
B. The chief complaint, history, examination findings, and clinical reasoning that support the encounter
[CORRECT]
C. The clinician's personal opinion about the patient
D. The patient's preferred pharmacy location
Correct Answer: B
Rationale: Medical necessity documentation must demonstrate, through the chief complaint, history, examination, and
clinical reasoning, why the service was required at the level billed. Insurance numbers and pharmacy information are
administrative details that do not establish medical necessity, and personal opinions are inappropriate in clinical
documentation. The D117 rubric evaluates whether documentation supports the medical necessity of the encounter with clear,
clinically relevant data and reasoning.
Documentation Form
Comprehensive 105-Question Exam with Complete Solutions
Latest 2026/2027 Update | Graduate Nursing Education
Western Governors University (WGU) | D117 Advanced Health Assessment
Exam Overview: This comprehensive examination contains 105 multiple-choice questions distributed across nine sections
aligned with the WGU D117 Advanced Health Assessment Documentation Form competencies. The exam is designed to
evaluate graduate-level knowledge and application of advanced health assessment documentation principles, including
SOAP note structure, subjective and objective data collection, comprehensive physical examination by body system,
clinical reasoning, ICD-10 coding, and documentation form completion competency. Questions are weighted across
cognitive levels with approximately 30% recall, 50% application, and 20% analysis. Approximately 75% of questions are
scenario-based or application-based, reflecting real clinical documentation challenges, while 25% test direct recall of
documentation standards. Each question includes a detailed rationale explaining the correct answer, why the distractors are
incorrect, and the underlying documentation principles aligned with the WGU D117 rubric. This exam reflects current
2026-2027 documentation standards, ICD-10-CM coding updates, and WGU documentation form expectations.
Exam Structure at a Glance
Section Question Range Topic Area
1 Q1 - Q12 Documentation Fundamentals and Standards
2 Q13 - Q30 Subjective Data Collection
3 Q31 - Q40 Objective Data - General and Integumentary
4 Q41 - Q54 Objective Data - HEENT, Neck, and Respiratory
5 Q55 - Q66 Objective Data - Cardiovascular and Peripheral Vascular
6 Q67 - Q78 Objective Data - Abdomen and Musculoskeletal
7 Q79 - Q90 Objective Data - Neurological and Mental Health
8 Q91 - Q100 Assessment, Differential Diagnosis, and Plan
9 Q101 - Q105 Documentation Form Completion and Competency
TOTAL 105 Questions Comprehensive WGU D117 Competency Coverage
Instructions for Use: Each question presents four answer choices (A, B, C, D) with exactly one correct answer marked
[CORRECT]. The rationale below each question explains the documentation principle, differentiates correct from incorrect
options, and provides complete-solution guidance aligned with WGU D117 rubric expectations. Use this exam for
self-assessment, competency preparation, and review of advanced health assessment documentation standards.
Section 1: Documentation Fundamentals and Standards (SOAP Format,
Charting Standards, HIPAA, & Legal Documentation)
,Q1: A nurse practitioner is completing a SOAP note for a patient seen in an outpatient clinic. The patient
states, "My chest has been hurting for the past three days." In which section of the WGU D117 documentation
form should this statement be recorded?
A. Assessment, because it reflects the clinician's interpretation of the symptom
B. Objective, because chest pain is an observable finding
C. Subjective, because it is the patient's verbatim report of symptoms [CORRECT]
D. Plan, because it determines the diagnostic workup needed
Correct Answer: C
Rationale: The Subjective section of a SOAP note captures all data reported by the patient, including the chief complaint,
history of present illness, and associated symptoms. A verbatim patient statement such as chest pain is inherently subjective
because it cannot be independently measured by the examiner. Placing it in the Objective section violates SOAP structure, the
Assessment section requires clinical reasoning rather than raw data, and the Plan section addresses interventions rather than
patient-reported information. The WGU D117 rubric specifically evaluates whether subjective data are correctly segregated
from objective findings.
Q2: During a comprehensive encounter, the advanced practice nurse documents: "BP 138/86, HR 82, RR 16,
T 37.0°C, SpO2 98% on room air." Which section of the documentation form is the appropriate location for
these findings?
A. Subjective, because vital signs are reported by the patient
B. Objective, because vital signs are measurable data obtained by the clinician [CORRECT]
C. Assessment, because abnormal values must be interpreted
D. Plan, because vital signs guide clinical decisions
Correct Answer: B
Rationale: Vital signs are measurable, observable data obtained directly by the clinician through the use of instruments such
as a sphygmomanometer and thermometer; therefore they belong in the Objective section of the SOAP note. The Subjective
section is reserved for patient-reported information, while the Assessment section synthesizes data into diagnoses, and the
Plan outlines interventions. Documenting vital signs in any section other than Objective is a common D117 rubric deduction
because it violates the fundamental distinction between measured data and interpreted findings.
Q3: A graduate nursing student is preparing to fax a patient's health assessment documentation to a
specialist. Under the HIPAA minimum necessary standard, which action best demonstrates compliance?
A. Fax the entire medical record to ensure the specialist has complete context
B. Fax only the portions of the record relevant to the referral and the specialist's role [CORRECT]
C. Fax only the demographic sheet to protect patient privacy
D. Fax the documentation without a cover sheet to streamline the process
Correct Answer: B
Rationale: The HIPAA minimum necessary standard requires that protected health information disclosed for treatment,
payment, or operations be limited to the minimum needed to accomplish the intended purpose. Faxing only the relevant
portions respects patient privacy while supporting continuity of care. Sending the entire record over-discloses protected
information, sending only demographics is insufficient for clinical decision-making, and omitting a cover sheet fails to
identify the recipient, increasing the risk of misdirected disclosure. The WGU D117 form expects documentation of
HIPAA-compliant handling of patient information.
,Q4: An advanced practice nurse realizes, two days after a patient encounter, that an important finding was
omitted from the original documentation. Which is the correct method for adding a late entry to the electronic
health record?
A. Delete the original note and create a new one with the added information
B. Alter the original entry to include the missing information and change the timestamp
C. Create a new addendum labeled "Late Entry" with the current date, time, and reference to the original
encounter [CORRECT]
D. Verbally inform the next clinician and skip formal documentation
Correct Answer: C
Rationale: Late entries must be documented as addenda that include the current date and time of the addition, a clear reference
to the original encounter, and the label "Late Entry" or "Addendum." Altering or deleting the original note violates legal
documentation standards and constitutes falsification of the medical record. Verbal reporting alone is insufficient because
documentation must support continuity of care and withstand legal scrutiny. The D117 rubric evaluates adherence to charting
standards including appropriate handling of late entries and corrections.
Q5: Which of the following entries best distinguishes subjective data from objective data in a comprehensive
health assessment note?
A. "Patient appears diaphoretic and reports chest pressure rated 7/10." [CORRECT]
B. "Patient has chest pain and elevated blood pressure."
C. "Patient is sick and looks unwell."
D. "Patient was treated for hypertension and feels better."
Correct Answer: A
Rationale: Option A clearly separates subjective data ("reports chest pressure rated 7/10") from objective data ("appears
diaphoretic"), reflecting proper SOAP documentation principles. Option B conflates subjective and objective findings without
distinguishing which is which, Option C uses vague non-clinical terminology that would be marked down on the D117 rubric,
and Option D mixes intervention with outcome without clear categorization. Graduate-level documentation must use precise
medical terminology and explicitly delineate subjective from objective content.
Q6: According to current charting standards, documentation of a patient encounter should be completed
within what timeframe to meet timeliness requirements?
A. Within 30 days of the encounter
B. By the end of the same shift or as soon as possible after the encounter [CORRECT]
C. Within one week of the patient encounter
D. Only when the insurance company requests the record
Correct Answer: B
Rationale: Timeliness in documentation requires that entries be completed by the end of the same shift or as soon as possible
after the encounter to ensure accuracy, support continuity of care, and meet regulatory standards. Delaying documentation by
30 days or one week risks memory decay and inaccurate entries, and waiting for an insurer request violates the principle of
contemporaneous charting. The D117 documentation form evaluates whether students adhere to timeliness expectations
consistent with professional nursing standards and institutional policy.
, Q7: A graduate nursing student makes an error while documenting in a paper chart. Which is the correct
method for correcting the error?
A. Use correction fluid to cover the error and write the correct information
B. Erase the error completely and rewrite the entry
C. Draw a single line through the error, write "error," initial and date it, then write the correct entry
[CORRECT]
D. Black out the error with a marker so it cannot be read
Correct Answer: C
Rationale: The legally accepted method for correcting paper documentation errors is to draw a single line through the
incorrect entry, write "error" nearby, initial and date the correction, then document the accurate information. This preserves
the original entry for legal review and demonstrates transparency. Correction fluid, erasure, and blacking out are forbidden
because they obscure the original content and may be construed as falsification. The D117 rubric assesses knowledge of
legally compliant documentation practices.
Q8: Which of the following entries is most appropriately placed in the Plan section of the SOAP note?
A. "Patient has community-acquired pneumonia."
B. "Crackles auscultated in right lower lobe."
C. "Start azithromycin 500 mg PO daily x 5 days; recheck in 1 week." [CORRECT]
D. "Patient reports productive cough for 4 days."
Correct Answer: C
Rationale: The Plan section of a SOAP note contains the diagnostic, pharmacologic, educational, and follow-up interventions
chosen by the clinician. Prescribing azithromycin and scheduling follow-up are concrete actions that belong in the Plan.
Option A is an Assessment (diagnosis), Option B is an Objective finding, and Option D is Subjective data. Confusing
Assessment with Plan is one of the most common D117 rubric deductions and reflects inadequate clinical reasoning
documentation.
Q9: When documenting medical necessity for an advanced health assessment, which element must be
explicitly stated to justify the level of service billed?
A. The patient's insurance identification number
B. The chief complaint, history, examination findings, and clinical reasoning that support the encounter
[CORRECT]
C. The clinician's personal opinion about the patient
D. The patient's preferred pharmacy location
Correct Answer: B
Rationale: Medical necessity documentation must demonstrate, through the chief complaint, history, examination, and
clinical reasoning, why the service was required at the level billed. Insurance numbers and pharmacy information are
administrative details that do not establish medical necessity, and personal opinions are inappropriate in clinical
documentation. The D117 rubric evaluates whether documentation supports the medical necessity of the encounter with clear,
clinically relevant data and reasoning.
