Nsg 211 Unit 5 Exam Test Questions
And 100% Correct Answers 2025-2026
Update.
sentinel events - Answer - any unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a patient or patients, not related to the natural course
of the patient's illness
patient medical record - Answer - medical record is used for legal documentation as well as for
communication among health team members, care panning, quality assurance, financial
reimbursement by insurers, education, and research
- nursing admission assessment
- history and physical exam by the primary care provider (H&P)
- primary care provider's orders
- POC or clinical pathway
- flowsheets documenting vital signs, intake and output (I&O), and routine assessments
- focused assessment sheets
- medication administration record (MAR)
- lab and diagnostic testing results
- progress notes by different members of the health care team
- consultations
- discharge or transfer summary
high-risk errors in documentation - Answer - falsifying patient records
- failing to record changes in patient's condition
- failing to document the notification of primary care provider when patient's condition changes
- performing inadequate admission assessment
- failing to document completely
- failing to follow the agency's standards or policies on documentation
- charting in advance
,- medicare and medicaid stopped reimbursement for some never events because they are
preventable through the use of evidence based guidelines and should never occur
- it's important to document pre-existing conditions so that insurance will cover it for the
patient and not consider it a "never event" that occurred while in hospital
principles governing documentation - Answer - quality documentation of assessment data
remains confidential and is accurate, complete, organized, timely, and concise
confidentiality and HIPAA - Answer - keeping information private
- applies to computerized and written medical records and any info pertaining to health status
or care received
HIPAA
- The Health Insurance Portability and Accountability Act
- regulates all areas of information managment, including reimbursement, coding, and security
of records
narrative note - Answer - type of progress note
- unstructured paragraphs recording relevant assessments and nursing activities during a shift or
visit
- written in phases, usually time sequenced
- ex. "4/18/08, 15:00, 37*c, 98 beats/min, 22 breaths/min, 130/82 mmHg. Pt c/o pain 8/10;
states he is using his PCA but it doesn't help. Notified MD of pain level at 14:30. Pain is
throbbing from fingers to elbow; has gotten worse over last 30 minutes. Pain increases with
movement. Fingers of left hand pink, warm, able to move with strong pulse and no c/o pain
with movement. Right hand cool and pale with cap refill 6 seconds. S. Roberts, RN
SOAP notes - Answer - type of progress note
- focus on a single problem
S: subjective assessment findings
O: objective assessment findings
A: analysis of assessment data to identify a problem or indicate whether the problem is
improving or worsening
, PIE notes - Answer - type of progress note
- it's goal is to incorporate the POC into the progress note
- patient assessments are not part of the PIE note
P: problem
I: intervention
E: evaluation
- ex. pg 70
DAR notes - Answer - type of progress note
- organizes entries by data, action, and response
- can focus on areas of strengths, as well as medical difficulties, family concerns, or nursing
diagnoses
D: data
A: action
R: response
- ex. pg 70
charting by exception - Answer - uses predetermined standards and norms to record only
significant assessment data
communication barriers - Answer - lack of structured format for communication
- lack of standards and policies for communication
- uncertainty about who is responsible and should be contacted
- hierarchy of relationships
- differences in ethnic background
- poor clinical decision making regarding what needs to be reported
- different communication styles of nurses and doctors
And 100% Correct Answers 2025-2026
Update.
sentinel events - Answer - any unanticipated event in a healthcare setting resulting in death or
serious physical or psychological injury to a patient or patients, not related to the natural course
of the patient's illness
patient medical record - Answer - medical record is used for legal documentation as well as for
communication among health team members, care panning, quality assurance, financial
reimbursement by insurers, education, and research
- nursing admission assessment
- history and physical exam by the primary care provider (H&P)
- primary care provider's orders
- POC or clinical pathway
- flowsheets documenting vital signs, intake and output (I&O), and routine assessments
- focused assessment sheets
- medication administration record (MAR)
- lab and diagnostic testing results
- progress notes by different members of the health care team
- consultations
- discharge or transfer summary
high-risk errors in documentation - Answer - falsifying patient records
- failing to record changes in patient's condition
- failing to document the notification of primary care provider when patient's condition changes
- performing inadequate admission assessment
- failing to document completely
- failing to follow the agency's standards or policies on documentation
- charting in advance
,- medicare and medicaid stopped reimbursement for some never events because they are
preventable through the use of evidence based guidelines and should never occur
- it's important to document pre-existing conditions so that insurance will cover it for the
patient and not consider it a "never event" that occurred while in hospital
principles governing documentation - Answer - quality documentation of assessment data
remains confidential and is accurate, complete, organized, timely, and concise
confidentiality and HIPAA - Answer - keeping information private
- applies to computerized and written medical records and any info pertaining to health status
or care received
HIPAA
- The Health Insurance Portability and Accountability Act
- regulates all areas of information managment, including reimbursement, coding, and security
of records
narrative note - Answer - type of progress note
- unstructured paragraphs recording relevant assessments and nursing activities during a shift or
visit
- written in phases, usually time sequenced
- ex. "4/18/08, 15:00, 37*c, 98 beats/min, 22 breaths/min, 130/82 mmHg. Pt c/o pain 8/10;
states he is using his PCA but it doesn't help. Notified MD of pain level at 14:30. Pain is
throbbing from fingers to elbow; has gotten worse over last 30 minutes. Pain increases with
movement. Fingers of left hand pink, warm, able to move with strong pulse and no c/o pain
with movement. Right hand cool and pale with cap refill 6 seconds. S. Roberts, RN
SOAP notes - Answer - type of progress note
- focus on a single problem
S: subjective assessment findings
O: objective assessment findings
A: analysis of assessment data to identify a problem or indicate whether the problem is
improving or worsening
, PIE notes - Answer - type of progress note
- it's goal is to incorporate the POC into the progress note
- patient assessments are not part of the PIE note
P: problem
I: intervention
E: evaluation
- ex. pg 70
DAR notes - Answer - type of progress note
- organizes entries by data, action, and response
- can focus on areas of strengths, as well as medical difficulties, family concerns, or nursing
diagnoses
D: data
A: action
R: response
- ex. pg 70
charting by exception - Answer - uses predetermined standards and norms to record only
significant assessment data
communication barriers - Answer - lack of structured format for communication
- lack of standards and policies for communication
- uncertainty about who is responsible and should be contacted
- hierarchy of relationships
- differences in ethnic background
- poor clinical decision making regarding what needs to be reported
- different communication styles of nurses and doctors
