Foundations 104 Chapter 7-8
Documentation Exam Questions with
correct Answers 2025/2026 A+ Graded
100% Verified
Documentation (Charting) - ANS-a written record of the history, treatment, care, and response
of the patient while under the care of a health care provider. Also, is a guide for reimbursement
of costs of care, provides data for quality assurance studies, may serve as evidence of care in a
court of law, and shows the use of the nursing process.
Medical Record (chart) - ANS-record that contains all orders, tests, treatments, and care that
occurred while the person was under the care of the health care provider. This chart is a
communication tool for the professionals involved in patient care.
True - ANS-True/False
Insurance companies and Medicare rely on documentation to determine actual length of stay,
procedures performed, and diagnoses established and to calculate charges due for
reimbursement.
The Medical Record - ANS-is a legal record and can be used as evidence of events that
occurred or treatment that was given. When documentation is thorough, the record provides a
way to show that standards of care have been met.
Face Sheet - ANS-This form contains Patient data, including the patient's name, address,
phone number, next of kin, hospital identification number, religious preference, place of
employment, insurance company, occupation, name of admitting physician, and admitting
diagnosis.
Physician's Orders - ANS-This form/order is physician's directives for patient care
Graphic Sheet - ANS-Record of serial measurements and observations, such as temperature,
pulse, respiration, blood pressure, weight
, Nursing Care Plan - ANS-Care plan for the patient, including nursing diagnoses, goals and
expected outcomes, and nursing interventions
Nurse's Notes - ANS-Written report of the nursing process (i.e., assessment, nursing diagnosis,
planning, implementation, and evaluation); record of interventions implemented and the patient's
response to them
Care Flow Sheet - ANS-Form on which check marks or short entries are made to indicate
dietary intake, type of bath, wound dressing changes, oxygen in use, physician visits, equipment
in use, level of activity, and so forth
Medication administration record (MAR) - ANS-Documentation of all medications ordered,
doses given, and doses not taken by the patient
History and physical examination forms - ANS-Physician's record of the patient's medical
history and findings of the current physical examination
Nurse's admission history and assessment - ANS-Nurse's current history, including usual
habits, medications usually taken, and physical assessment findings at admission
Chronological Order - ANS-events follow a liner time structure
Progress Sheet - ANS-Physician's notes or sheet regarding the patient's progress
Laboratory reports - ANS-Results of laboratory tests
Radiology Reports - ANS-Results of x-ray examinations
Admission Forms - ANS-Information on patient identification, conditions for admission, and
consent for general medical and nursing care
Intake and output (I&O) record - ANS-Serial record of 24-hr intake and output
Source-Oriented or Narrative Charting - ANS-Information in chronologic order, documents
patient's baseline condition for each shift, and indicates aspects of all steps of the nursing
process.
*Narrative charting (Each individual medical staff team member has their own. Ex: doctor,nurse
etc.)
Problem-Oriented Medical Record Charting (POMR) - ANS-Focuses on patient status rather
than on medical or nursing care
Five basic parts: database, problem list, plan, progress notes, and discharge summary
(SOAP format)
Documentation Exam Questions with
correct Answers 2025/2026 A+ Graded
100% Verified
Documentation (Charting) - ANS-a written record of the history, treatment, care, and response
of the patient while under the care of a health care provider. Also, is a guide for reimbursement
of costs of care, provides data for quality assurance studies, may serve as evidence of care in a
court of law, and shows the use of the nursing process.
Medical Record (chart) - ANS-record that contains all orders, tests, treatments, and care that
occurred while the person was under the care of the health care provider. This chart is a
communication tool for the professionals involved in patient care.
True - ANS-True/False
Insurance companies and Medicare rely on documentation to determine actual length of stay,
procedures performed, and diagnoses established and to calculate charges due for
reimbursement.
The Medical Record - ANS-is a legal record and can be used as evidence of events that
occurred or treatment that was given. When documentation is thorough, the record provides a
way to show that standards of care have been met.
Face Sheet - ANS-This form contains Patient data, including the patient's name, address,
phone number, next of kin, hospital identification number, religious preference, place of
employment, insurance company, occupation, name of admitting physician, and admitting
diagnosis.
Physician's Orders - ANS-This form/order is physician's directives for patient care
Graphic Sheet - ANS-Record of serial measurements and observations, such as temperature,
pulse, respiration, blood pressure, weight
, Nursing Care Plan - ANS-Care plan for the patient, including nursing diagnoses, goals and
expected outcomes, and nursing interventions
Nurse's Notes - ANS-Written report of the nursing process (i.e., assessment, nursing diagnosis,
planning, implementation, and evaluation); record of interventions implemented and the patient's
response to them
Care Flow Sheet - ANS-Form on which check marks or short entries are made to indicate
dietary intake, type of bath, wound dressing changes, oxygen in use, physician visits, equipment
in use, level of activity, and so forth
Medication administration record (MAR) - ANS-Documentation of all medications ordered,
doses given, and doses not taken by the patient
History and physical examination forms - ANS-Physician's record of the patient's medical
history and findings of the current physical examination
Nurse's admission history and assessment - ANS-Nurse's current history, including usual
habits, medications usually taken, and physical assessment findings at admission
Chronological Order - ANS-events follow a liner time structure
Progress Sheet - ANS-Physician's notes or sheet regarding the patient's progress
Laboratory reports - ANS-Results of laboratory tests
Radiology Reports - ANS-Results of x-ray examinations
Admission Forms - ANS-Information on patient identification, conditions for admission, and
consent for general medical and nursing care
Intake and output (I&O) record - ANS-Serial record of 24-hr intake and output
Source-Oriented or Narrative Charting - ANS-Information in chronologic order, documents
patient's baseline condition for each shift, and indicates aspects of all steps of the nursing
process.
*Narrative charting (Each individual medical staff team member has their own. Ex: doctor,nurse
etc.)
Problem-Oriented Medical Record Charting (POMR) - ANS-Focuses on patient status rather
than on medical or nursing care
Five basic parts: database, problem list, plan, progress notes, and discharge summary
(SOAP format)
