DOCUMENTATION ELECTRONIC HEALTH
RECORD EXAM SCRIPT 2026 FULL QUESTIONS
WITH 100% CORRECT ANSWERS
◉ examples of healthcare documents. Answer: paper or electronic health
records
faxes
emails
audio or videotape
images
◉ purpose of EHR. Answer: facilitation of info for continuity, quality,
and safety of care in a clear and concise manner
◉ nurses need to document. Answer: from baseline to patient response
to intervention and patient education
◉ Standards for documentation. Answer: -healthcare organization's
policies and procedures
-each organization's documentation should follow procedures
established by the Joint Commission's (TJC) Standards and Elements of
, Performance (must have record for each pt. and only allow authorized
personnel to see)
◉ Centers for Medicare and Medicaid Services (CMS) principles of
documentation. Answer: completeness and legibility
reasons for pt. encounter (assessments and diagnosis)
plan of care
patient progress
any change in care including treatment, date, and observer identity
◉ American Nurses Association (ANA) principles of documentation.
Answer: documentation
evaluation and training
policies and procedures
protection systems
entries and standardized terminologies
-high quality documentation reflects nursing process and includes
accessibility, accuracy, relevance, auditability, timeliness,
thoughtfulness, and retrieveability
◉ Diagnostic Related Groups (DRG) Principles of documentation.
Answer: reimbursement requires proper documentation supporting
hospital stays (ex. Reimbursement from insurance companies, Medicare,
Medicaid)
RECORD EXAM SCRIPT 2026 FULL QUESTIONS
WITH 100% CORRECT ANSWERS
◉ examples of healthcare documents. Answer: paper or electronic health
records
faxes
emails
audio or videotape
images
◉ purpose of EHR. Answer: facilitation of info for continuity, quality,
and safety of care in a clear and concise manner
◉ nurses need to document. Answer: from baseline to patient response
to intervention and patient education
◉ Standards for documentation. Answer: -healthcare organization's
policies and procedures
-each organization's documentation should follow procedures
established by the Joint Commission's (TJC) Standards and Elements of
, Performance (must have record for each pt. and only allow authorized
personnel to see)
◉ Centers for Medicare and Medicaid Services (CMS) principles of
documentation. Answer: completeness and legibility
reasons for pt. encounter (assessments and diagnosis)
plan of care
patient progress
any change in care including treatment, date, and observer identity
◉ American Nurses Association (ANA) principles of documentation.
Answer: documentation
evaluation and training
policies and procedures
protection systems
entries and standardized terminologies
-high quality documentation reflects nursing process and includes
accessibility, accuracy, relevance, auditability, timeliness,
thoughtfulness, and retrieveability
◉ Diagnostic Related Groups (DRG) Principles of documentation.
Answer: reimbursement requires proper documentation supporting
hospital stays (ex. Reimbursement from insurance companies, Medicare,
Medicaid)
