NUR 134 Documentation UPDATED
ACTUAL Exam Questions and CORRECT
Answers
documentation - CORRECT ANSWER the written or electronic legal record of all
pertinent interactions with the patient-assessing, diagnosing, planning, implementing, and
evaluating
patient record - CORRECT ANSWER compilation of a patient's health information that
permanently documents all care given and reflects the quality of care provided
reimbursement/financial, legal, research - CORRECT ANSWER the patient record may be
used for _______/_______ purposes, as a ________ document, or for _________ & education
the chart - CORRECT ANSWER The patient record is known as "____ _____"
Electronic medical record (EMR) - CORRECT ANSWER An electronic "patient record";
utilized by agencies with the same ownership
Electronic health record (EHR) - CORRECT ANSWER Similar to EMR; more
comprehensive, information is shared among more healthcare providers
Health information exchange (HIE) - CORRECT ANSWER organization that provides
services to enable the electronic sharing of health information
content, timing, format, accountability, confidentiality - CORRECT ANSWER What are
the 5 documentation guidelines?
content - CORRECT ANSWER guideline; complete, accurate, concise, current, organized,
and descriptive
, timing - CORRECT ANSWER guideline; timely manner, chronologically
False - CORRECT ANSWER (T/F) It is acceptable to "pre chart"
Military - CORRECT ANSWER Always use ________ time when documenting
format - CORRECT ANSWER guideline; correct chart, utilized correct forms, standard
terminology, and appropriate abbreviations
accountability - CORRECT ANSWER guideline; signature/title to each entry
confidentiality - CORRECT ANSWER guideline; HIPAA--maintain privacy/protect
information
patient care summary - CORRECT ANSWER overview of valuable patient information;
"snapshot" of patient; includes baseline information, demographics, and diagnosis
progress notes/nurse notes - CORRECT ANSWER informs caregivers of progress toward
outcomes; utilized by physicians and nurses; descriptive/accurate/concise
progress notes/nurse notes - CORRECT ANSWER SOAP, PIE, APIE, and Narrative notes
are all examples of what?
flow sheets - CORRECT ANSWER tools used to efficiently chart routine care provided,
assessment data, and patient activities/rounding; easy to navigate
graphic records - CORRECT ANSWER form used to record specific variables such as v/s,
I&O, and ht/wt; easy to track "trends" over a designated time frame
ACTUAL Exam Questions and CORRECT
Answers
documentation - CORRECT ANSWER the written or electronic legal record of all
pertinent interactions with the patient-assessing, diagnosing, planning, implementing, and
evaluating
patient record - CORRECT ANSWER compilation of a patient's health information that
permanently documents all care given and reflects the quality of care provided
reimbursement/financial, legal, research - CORRECT ANSWER the patient record may be
used for _______/_______ purposes, as a ________ document, or for _________ & education
the chart - CORRECT ANSWER The patient record is known as "____ _____"
Electronic medical record (EMR) - CORRECT ANSWER An electronic "patient record";
utilized by agencies with the same ownership
Electronic health record (EHR) - CORRECT ANSWER Similar to EMR; more
comprehensive, information is shared among more healthcare providers
Health information exchange (HIE) - CORRECT ANSWER organization that provides
services to enable the electronic sharing of health information
content, timing, format, accountability, confidentiality - CORRECT ANSWER What are
the 5 documentation guidelines?
content - CORRECT ANSWER guideline; complete, accurate, concise, current, organized,
and descriptive
, timing - CORRECT ANSWER guideline; timely manner, chronologically
False - CORRECT ANSWER (T/F) It is acceptable to "pre chart"
Military - CORRECT ANSWER Always use ________ time when documenting
format - CORRECT ANSWER guideline; correct chart, utilized correct forms, standard
terminology, and appropriate abbreviations
accountability - CORRECT ANSWER guideline; signature/title to each entry
confidentiality - CORRECT ANSWER guideline; HIPAA--maintain privacy/protect
information
patient care summary - CORRECT ANSWER overview of valuable patient information;
"snapshot" of patient; includes baseline information, demographics, and diagnosis
progress notes/nurse notes - CORRECT ANSWER informs caregivers of progress toward
outcomes; utilized by physicians and nurses; descriptive/accurate/concise
progress notes/nurse notes - CORRECT ANSWER SOAP, PIE, APIE, and Narrative notes
are all examples of what?
flow sheets - CORRECT ANSWER tools used to efficiently chart routine care provided,
assessment data, and patient activities/rounding; easy to navigate
graphic records - CORRECT ANSWER form used to record specific variables such as v/s,
I&O, and ht/wt; easy to track "trends" over a designated time frame
