DOCUMENTATION ELECTRONIC HEALTH
RECORD COMPREHENSIVE EXAM 2026
QUESTIONS AND SOLUTIONS GRADED A+
◉ Documentation Standards and Principles. Answer: -Stanards
established by health organization and should agree with JC and CMMS
standards, ANA principles
-Principles from Centers for Medicare and Medicaid Services (CMMS):
completeness; legibility; reason for patient encounters; include
assessments, diagnosis, plan of care, patient progress, and changes in
diagnosis and treatment
-These standards are needed for reimbursement by diagnostic-related
groups (each admission has a DRG code)
◉ The Medical Record. Answer: -Contains comprehensive information
about patient health care encounters; demographic, administrative, and
clinical data
-Communication tool
-Single data access point for staff
-Legal document that must meet guidelines
-Promotes continuity of care
-Clinical data archive
, -Tool for research
◉ Ethical, Legal, and Professional Practice. Answer: -The medical
record is the legal documentation of care provided to a patient
-In event of litigation, the medical record is often the only available
evidence of the event in question
-Medical record documentation should be based on fact, not opinions -
clear and concise
-Every note must include a date, time, and signature with credentials
-Ethical practice dictates that the nurse documents only interventions
that are performed
-Medical record entries cannot be altered or obliterated
◉ Written Medical Records. Answer: -Structure of information within
the record has changed
-Potential problems of paper records:
Can be difficult to locate
Single-user access
Fragile, can be damaged, can degrade
Handwriting may be illegible
Storage can be problematic
-Traditional guidelines: black ink; include date, time, and signature; no
blank spaces
RECORD COMPREHENSIVE EXAM 2026
QUESTIONS AND SOLUTIONS GRADED A+
◉ Documentation Standards and Principles. Answer: -Stanards
established by health organization and should agree with JC and CMMS
standards, ANA principles
-Principles from Centers for Medicare and Medicaid Services (CMMS):
completeness; legibility; reason for patient encounters; include
assessments, diagnosis, plan of care, patient progress, and changes in
diagnosis and treatment
-These standards are needed for reimbursement by diagnostic-related
groups (each admission has a DRG code)
◉ The Medical Record. Answer: -Contains comprehensive information
about patient health care encounters; demographic, administrative, and
clinical data
-Communication tool
-Single data access point for staff
-Legal document that must meet guidelines
-Promotes continuity of care
-Clinical data archive
, -Tool for research
◉ Ethical, Legal, and Professional Practice. Answer: -The medical
record is the legal documentation of care provided to a patient
-In event of litigation, the medical record is often the only available
evidence of the event in question
-Medical record documentation should be based on fact, not opinions -
clear and concise
-Every note must include a date, time, and signature with credentials
-Ethical practice dictates that the nurse documents only interventions
that are performed
-Medical record entries cannot be altered or obliterated
◉ Written Medical Records. Answer: -Structure of information within
the record has changed
-Potential problems of paper records:
Can be difficult to locate
Single-user access
Fragile, can be damaged, can degrade
Handwriting may be illegible
Storage can be problematic
-Traditional guidelines: black ink; include date, time, and signature; no
blank spaces
