CHAPTER 26: DOCUMENTATION AND INFORMATICS
QUESTIONS WITH 100% RATED ANSWERS 2025/2026
LATEST UPDATE/GET A+
Accreditation - process whereby recognition is granted to an educational program for
maintaining standards that qualify its graduates for professional practice; to provide with
credentials
acuity ratings -
case management - Organized system for delivering health care to an individual patient
or group of patients across an episode of illness and/or a continuum of care; includes
assessment and development of a plan of care, coordination of all services, referral,
and follow-up; usually assigned to one professional.
Charting by exception (CBE) - Charting methodology in which data are entered only
when there is an exception from that which is normal or expected
Clinical Decision Support System - problem-solving approach that nurses use to define
patient problems and select appropriate treatments
Clinical Information Systems - computer-based system that collects, stores and
manipulates data to allow health care providers to make informed decision-making
clinical practice guidelines - standardized care plans
Computerized provider order entry (CPOE) - a process by which a health care provider
directly enters orders for patient care into the hospital info system
critical pathways - interprofessional care plans that identify patient problems, key
interventions, and expected outcomes within an established time frame
DAR - data, action, response
Diagnosis-related groups (DRGs) - classifications based on a patient's primary and
secondary medical diagnoses that are used as the basis for establishing Medicare
reimbursement for patient care
Documentation - a nursing action that produces a written account of pertinent patient
data, nursing clinical decisions and interventions, and patient responses in a health
record
Electronic Health Record (EHR) - An electronic record of health-related info
Electronic Medical Record (EMR) - Patient medical record from a single medical
practice, hospital, or pharmacy
,firewall - A combo of hardware and software that creates a buffer between an internal
network and the Internet to prevent unauthorized access
flow sheets - Documents on which frequent observations or specific measurements are
recorded.
Focus charting - Charting methodology for structuring progress notes according to the
focus of the note.
Health Informatics - Application of computer and information science in all basic and
applied biomedical sciences to facilitate the acquisition, processing, interpretation,
optimal use, and communication of health-related data.
Incident (occurrence) report - confidential document that describes any patient accident
while the person is on the premises of a health care agency
Information Technology (IT) - the management and processing of info generally with the
assistance of computers
Nursing clinical information system (NCIS) - A system that incorporates the principles of
nursing informatics to support the work that nurses do by facilitating documentation of
nursing process activities and offering resources for managing nursing care delivery.
Nursing informatics - the use of info and computer technology to support all aspects of
nursing practice
PIE - problem, intervention, evaluate
problem-oriented medical record (POMR) - a system of organizing documentation to
place the primary focus on patients' individual problems
SOAP - subjective, objective, assessment, plan
SOAPIE - subjective, objective, assessment, plan, intervention, evaluation
standardized care plans - Written care plans used for groups of patients who have
similar health care problems.
variances - unexpected outcomes, unmet goals, and interventions not specified within
the critical pathway
Each note in focus charting includes: - data, actions, and patient response
The nurse is learning various methods of patient charting. Which are aspects of charting
by exception? (Select all that apply.)
, 1) Documentation of patient concerns.
2) Documentation of deviations.
3) Use of a shorthand method.
4) Documentation of significant findings.
5) Inclusion of subjective assessment findings. - -Documentation of deviations.
-Use of a shorthand method.
-Documentation of significant findings.
The nurse is learning various methods of DAR. Which are aspects of charting by
exception?
1) Documentation of patient concerns.
2) Documentation of deviations.
3) Use of a shorthand method.
4) Documentation of significant findings.
5) Inclusion of subjective assessment findings. - Documentation of patient concerns.
The nurse is learning various methods of narrative charting. Which are aspects of
charting by exception?
1) Documentation of patient concerns.
2) Documentation of deviations.
3) Use of a shorthand method.
4) Documentation of significant findings.
5) Inclusion of subjective assessment findings. - Inclusion of subjective assessment
findings.
Using the SOAP format, which represents the appropriate P statement?
1) Reposition the patient on the right side. Encourage the patient to use the patient-
controlled analgesia (PCA) device.
2) The patient states, "The pain increases every time I try to turn on my left side."
3) Acute pain is related to tissue injury from a surgical incision.
4) Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no
drainage. Pain noted on mild palpation. - Reposition the patient on the right side.
Encourage the patient to use the patient-controlled analgesia (PCA) device.
Using the SOAP format, which represents the appropriate S statement?
1) Reposition the patient on the right side. Encourage the patient to use the patient-
controlled analgesia (PCA) device.
2) The patient states, "The pain increases every time I try to turn on my left side."
3) Acute pain is related to tissue injury from a surgical incision.
QUESTIONS WITH 100% RATED ANSWERS 2025/2026
LATEST UPDATE/GET A+
Accreditation - process whereby recognition is granted to an educational program for
maintaining standards that qualify its graduates for professional practice; to provide with
credentials
acuity ratings -
case management - Organized system for delivering health care to an individual patient
or group of patients across an episode of illness and/or a continuum of care; includes
assessment and development of a plan of care, coordination of all services, referral,
and follow-up; usually assigned to one professional.
Charting by exception (CBE) - Charting methodology in which data are entered only
when there is an exception from that which is normal or expected
Clinical Decision Support System - problem-solving approach that nurses use to define
patient problems and select appropriate treatments
Clinical Information Systems - computer-based system that collects, stores and
manipulates data to allow health care providers to make informed decision-making
clinical practice guidelines - standardized care plans
Computerized provider order entry (CPOE) - a process by which a health care provider
directly enters orders for patient care into the hospital info system
critical pathways - interprofessional care plans that identify patient problems, key
interventions, and expected outcomes within an established time frame
DAR - data, action, response
Diagnosis-related groups (DRGs) - classifications based on a patient's primary and
secondary medical diagnoses that are used as the basis for establishing Medicare
reimbursement for patient care
Documentation - a nursing action that produces a written account of pertinent patient
data, nursing clinical decisions and interventions, and patient responses in a health
record
Electronic Health Record (EHR) - An electronic record of health-related info
Electronic Medical Record (EMR) - Patient medical record from a single medical
practice, hospital, or pharmacy
,firewall - A combo of hardware and software that creates a buffer between an internal
network and the Internet to prevent unauthorized access
flow sheets - Documents on which frequent observations or specific measurements are
recorded.
Focus charting - Charting methodology for structuring progress notes according to the
focus of the note.
Health Informatics - Application of computer and information science in all basic and
applied biomedical sciences to facilitate the acquisition, processing, interpretation,
optimal use, and communication of health-related data.
Incident (occurrence) report - confidential document that describes any patient accident
while the person is on the premises of a health care agency
Information Technology (IT) - the management and processing of info generally with the
assistance of computers
Nursing clinical information system (NCIS) - A system that incorporates the principles of
nursing informatics to support the work that nurses do by facilitating documentation of
nursing process activities and offering resources for managing nursing care delivery.
Nursing informatics - the use of info and computer technology to support all aspects of
nursing practice
PIE - problem, intervention, evaluate
problem-oriented medical record (POMR) - a system of organizing documentation to
place the primary focus on patients' individual problems
SOAP - subjective, objective, assessment, plan
SOAPIE - subjective, objective, assessment, plan, intervention, evaluation
standardized care plans - Written care plans used for groups of patients who have
similar health care problems.
variances - unexpected outcomes, unmet goals, and interventions not specified within
the critical pathway
Each note in focus charting includes: - data, actions, and patient response
The nurse is learning various methods of patient charting. Which are aspects of charting
by exception? (Select all that apply.)
, 1) Documentation of patient concerns.
2) Documentation of deviations.
3) Use of a shorthand method.
4) Documentation of significant findings.
5) Inclusion of subjective assessment findings. - -Documentation of deviations.
-Use of a shorthand method.
-Documentation of significant findings.
The nurse is learning various methods of DAR. Which are aspects of charting by
exception?
1) Documentation of patient concerns.
2) Documentation of deviations.
3) Use of a shorthand method.
4) Documentation of significant findings.
5) Inclusion of subjective assessment findings. - Documentation of patient concerns.
The nurse is learning various methods of narrative charting. Which are aspects of
charting by exception?
1) Documentation of patient concerns.
2) Documentation of deviations.
3) Use of a shorthand method.
4) Documentation of significant findings.
5) Inclusion of subjective assessment findings. - Inclusion of subjective assessment
findings.
Using the SOAP format, which represents the appropriate P statement?
1) Reposition the patient on the right side. Encourage the patient to use the patient-
controlled analgesia (PCA) device.
2) The patient states, "The pain increases every time I try to turn on my left side."
3) Acute pain is related to tissue injury from a surgical incision.
4) Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no
drainage. Pain noted on mild palpation. - Reposition the patient on the right side.
Encourage the patient to use the patient-controlled analgesia (PCA) device.
Using the SOAP format, which represents the appropriate S statement?
1) Reposition the patient on the right side. Encourage the patient to use the patient-
controlled analgesia (PCA) device.
2) The patient states, "The pain increases every time I try to turn on my left side."
3) Acute pain is related to tissue injury from a surgical incision.
