WGU D117 Advanced Health Assessment
Documentation ACTUAL EXAM
2026/2027 | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1: Health History Components (15 Questions)
Q1: A patient tells the nurse practitioner, "My chest pain started yesterday around 3 PM. It's a sharp
pain right in the middle of my chest. It gets worse when I walk up stairs and feels better when I sit still."
This statement is best documented in which part of the health history?
A. Past Medical History
B. Review of Systems
C. History of Present Illness [CORRECT]
D. Social History
Correct Answer: C
Rationale: HPI documents the patient's chief complaint using OLDCARTS (Onset, Location, Character,
Aggravating/Relieving factors). This patient statement includes onset (yesterday 3 PM), location (mid-
chest), character (sharp), aggravating (stairs), and relieving (sitting still). Proper HPI documentation
requires capturing all OLDCARTS elements to support clinical reasoning and differential diagnosis
formulation.
Q2: Under the Joint Commission's "Do Not Use" list, which abbreviation is prohibited because it can be
mistaken for "IV" or "10"?
A. QD
B. U [CORRECT]
C. MS
D. IU
Correct Answer: B
,Rationale: "U" for units is prohibited because poor handwriting can lead to misinterpretation as "0", "4",
or "IV". The correct documentation is to write the word "units" in full. This abbreviation error has
resulted in medication errors involving insulin and heparin, making strict adherence to the "Do Not Use"
list essential for patient safety.
Q3: A 54-year-old patient states, "I had my appendix removed when I was 12, and I was hospitalized for
pneumonia two years ago. I get a flu shot every year." Where should this information be documented?
A. Family History
B. Social History
C. Past Medical History [CORRECT]
D. Chief Complaint
Correct Answer: C
Rationale: Past Medical History (PMH) documents all previous illnesses, surgeries, hospitalizations,
injuries, immunizations, and screenings. This patient's statement includes surgery (appendectomy),
hospitalization (pneumonia), and immunizations (annual flu shots), all of which belong in the PMH
section.
Q4: When documenting a patient's social history, which element is essential to assess but often under-
documented in advanced practice?
A. Current medications
B. Living situation and social support [CORRECT]
C. Previous surgical procedures
D. Family genetic disorders
Correct Answer: B
Rationale: Living situation and social support are critical components of social history that impact care
planning, medication adherence, and discharge planning. Documentation must include occupation,
tobacco/alcohol/substance use, living arrangements, sexual history, and support systems to assess
health determinants and barriers to care.
Q5: A patient reports, "My father died of a heart attack at age 45, my mother has diabetes, and my
sister was diagnosed with breast cancer last year." This information belongs in which section?
A. Review of Systems
B. Family History [CORRECT]
, C. History of Present Illness
D. Physical Examination
Correct Answer: B
Rationale: Family History documents genetic predispositions, hereditary conditions, and age of onset of
diseases in first- and second-degree relatives. This information guides screening recommendations (e.g.,
early cardiac screening for the patient with paternal early MI) and risk assessment for hereditary cancer
syndromes.
Q6: Using OLDCARTS, which component is missing from this HPI documentation: "Patient reports dull,
aching low back pain that began 3 days ago after lifting heavy boxes at work. Pain is constant and rated
6/10"?
A. Location
B. Timing
C. Relieving factors [CORRECT]
D. Character
Correct Answer: C
Rationale: A complete HPI using OLDCARTS requires documentation of Onset, Location, Duration,
Character, Aggravating factors, Relieving factors, Timing, and Severity. This documentation includes
onset (3 days ago), location (low back), character (dull, aching), aggravating (lifting heavy boxes), timing
(constant), and severity (6/10), but lacks relieving factors.
Q7: The Review of Systems (ROS) differs from the Physical Examination in that the ROS:
A. Is performed only by physicians
B. Documents only abnormal findings
C. Is based on patient-reported symptoms [CORRECT]
D. Requires diagnostic imaging
Correct Answer: C
Rationale: ROS is a patient-reported inventory of symptoms by body system, distinguishing it from the
Physical Examination, which documents clinician-observed or elicited findings. ROS documents both
positive symptoms and pertinent negatives, while the physical exam documents objective, measurable
data obtained through inspection, palpation, percussion, and auscultation.
Documentation ACTUAL EXAM
2026/2027 | Verified Q&A | Pass
Guaranteed - A+ Graded
Section 1: Health History Components (15 Questions)
Q1: A patient tells the nurse practitioner, "My chest pain started yesterday around 3 PM. It's a sharp
pain right in the middle of my chest. It gets worse when I walk up stairs and feels better when I sit still."
This statement is best documented in which part of the health history?
A. Past Medical History
B. Review of Systems
C. History of Present Illness [CORRECT]
D. Social History
Correct Answer: C
Rationale: HPI documents the patient's chief complaint using OLDCARTS (Onset, Location, Character,
Aggravating/Relieving factors). This patient statement includes onset (yesterday 3 PM), location (mid-
chest), character (sharp), aggravating (stairs), and relieving (sitting still). Proper HPI documentation
requires capturing all OLDCARTS elements to support clinical reasoning and differential diagnosis
formulation.
Q2: Under the Joint Commission's "Do Not Use" list, which abbreviation is prohibited because it can be
mistaken for "IV" or "10"?
A. QD
B. U [CORRECT]
C. MS
D. IU
Correct Answer: B
,Rationale: "U" for units is prohibited because poor handwriting can lead to misinterpretation as "0", "4",
or "IV". The correct documentation is to write the word "units" in full. This abbreviation error has
resulted in medication errors involving insulin and heparin, making strict adherence to the "Do Not Use"
list essential for patient safety.
Q3: A 54-year-old patient states, "I had my appendix removed when I was 12, and I was hospitalized for
pneumonia two years ago. I get a flu shot every year." Where should this information be documented?
A. Family History
B. Social History
C. Past Medical History [CORRECT]
D. Chief Complaint
Correct Answer: C
Rationale: Past Medical History (PMH) documents all previous illnesses, surgeries, hospitalizations,
injuries, immunizations, and screenings. This patient's statement includes surgery (appendectomy),
hospitalization (pneumonia), and immunizations (annual flu shots), all of which belong in the PMH
section.
Q4: When documenting a patient's social history, which element is essential to assess but often under-
documented in advanced practice?
A. Current medications
B. Living situation and social support [CORRECT]
C. Previous surgical procedures
D. Family genetic disorders
Correct Answer: B
Rationale: Living situation and social support are critical components of social history that impact care
planning, medication adherence, and discharge planning. Documentation must include occupation,
tobacco/alcohol/substance use, living arrangements, sexual history, and support systems to assess
health determinants and barriers to care.
Q5: A patient reports, "My father died of a heart attack at age 45, my mother has diabetes, and my
sister was diagnosed with breast cancer last year." This information belongs in which section?
A. Review of Systems
B. Family History [CORRECT]
, C. History of Present Illness
D. Physical Examination
Correct Answer: B
Rationale: Family History documents genetic predispositions, hereditary conditions, and age of onset of
diseases in first- and second-degree relatives. This information guides screening recommendations (e.g.,
early cardiac screening for the patient with paternal early MI) and risk assessment for hereditary cancer
syndromes.
Q6: Using OLDCARTS, which component is missing from this HPI documentation: "Patient reports dull,
aching low back pain that began 3 days ago after lifting heavy boxes at work. Pain is constant and rated
6/10"?
A. Location
B. Timing
C. Relieving factors [CORRECT]
D. Character
Correct Answer: C
Rationale: A complete HPI using OLDCARTS requires documentation of Onset, Location, Duration,
Character, Aggravating factors, Relieving factors, Timing, and Severity. This documentation includes
onset (3 days ago), location (low back), character (dull, aching), aggravating (lifting heavy boxes), timing
(constant), and severity (6/10), but lacks relieving factors.
Q7: The Review of Systems (ROS) differs from the Physical Examination in that the ROS:
A. Is performed only by physicians
B. Documents only abnormal findings
C. Is based on patient-reported symptoms [CORRECT]
D. Requires diagnostic imaging
Correct Answer: C
Rationale: ROS is a patient-reported inventory of symptoms by body system, distinguishing it from the
Physical Examination, which documents clinician-observed or elicited findings. ROS documents both
positive symptoms and pertinent negatives, while the physical exam documents objective, measurable
data obtained through inspection, palpation, percussion, and auscultation.
