DOCUMENTATION ELECTRONIC HEALTH
RECORD STUDY GUIDE 2026 TEST PAPER
QUESTIONS AND SOLUTIONS
◉ High-quality nursing documentation reflects the nursing process.
Answer: The nurse identifies which statement to be true regarding
nursing documentation?
A. Standards for documentation are established by a national
commission.
B. Medical records should be accessible to everyone.
C. Documentation should not include the patient's diagnosis.
D. High-quality nursing documentation reflects the nursing process.
◉ It can be used as a tool for biomedical research and provide
education. Answer: The nurse identifies which true statement regarding
the medical record?
A. It serves as a major communication tool but is not a legal document.
B. It cannot be used to assess quality of care issues.
, C. It is not used to determine reimbursement claims.
D. It can be used as a tool for biomedical research and provide
education.
◉ Paper is fragile and susceptible to damage. Answer: The nurse knows
that paper records are being replaced by other forms of record keeping
for what reason?
A. Paper is fragile and susceptible to damage.
B. Paper records are always available to multiple people at a time.
C. Paper records can be stored without difficulty and are easily
retrievable.
D. Paper records are permanent and last indefinitely.
◉ Use black ink unless the facility allows a different color. Answer:
When the nurse is charting in the paper medical record, what action does
the nurse carry out?
A. Print his/her name since signatures are often not readable.
B. Omit nursing credentials since only the nurses chart
C. Skip a line between entries so that it looks neat.
D. Use black ink unless the facility allows a different color.
RECORD STUDY GUIDE 2026 TEST PAPER
QUESTIONS AND SOLUTIONS
◉ High-quality nursing documentation reflects the nursing process.
Answer: The nurse identifies which statement to be true regarding
nursing documentation?
A. Standards for documentation are established by a national
commission.
B. Medical records should be accessible to everyone.
C. Documentation should not include the patient's diagnosis.
D. High-quality nursing documentation reflects the nursing process.
◉ It can be used as a tool for biomedical research and provide
education. Answer: The nurse identifies which true statement regarding
the medical record?
A. It serves as a major communication tool but is not a legal document.
B. It cannot be used to assess quality of care issues.
, C. It is not used to determine reimbursement claims.
D. It can be used as a tool for biomedical research and provide
education.
◉ Paper is fragile and susceptible to damage. Answer: The nurse knows
that paper records are being replaced by other forms of record keeping
for what reason?
A. Paper is fragile and susceptible to damage.
B. Paper records are always available to multiple people at a time.
C. Paper records can be stored without difficulty and are easily
retrievable.
D. Paper records are permanent and last indefinitely.
◉ Use black ink unless the facility allows a different color. Answer:
When the nurse is charting in the paper medical record, what action does
the nurse carry out?
A. Print his/her name since signatures are often not readable.
B. Omit nursing credentials since only the nurses chart
C. Skip a line between entries so that it looks neat.
D. Use black ink unless the facility allows a different color.
