NUR 209/ NUR209 Exam 2 – Medical-
Surgical Nursing II Review| Fortis (Latest
2026/ 2027 Update) 100% Verified
Questions & Answers | Grade A
Communication: Team Documentation & Reporting
-
Purposes of the patient record
1. Assessment → comparison of objective and subjective assessment data gathered
by all team members
2. Care Planning → availability of all assessment data allows nurses to more
accurately develop nursing diagnoses, goals, interventions and evaluation of patient
care
3. Legal Document → can be used to prove or disprove injuries a patient incurred
unintentionally or to implicate or absolve improper care
4. Quality Assurance → determines whether certain care standards were met &
documented
▪Audits of patient records that are included are part of accreditation requirements
▪Constantly revising certain procedures, policies based on EBP (research)
5. Reimbursement → basis for decisions regarding care and subsequent
reimbursement to agency
▪Federal agencies of the state look at documentation for reimbursement eligibility
▪Ex: look to see how many unreported cases of falls or bed sores happened last year
,▪Ex: if patient develops bed sore and no one checks it or 48 hours, then the nurse
notices it and says “Yeah she had that when they came in” but it was never documented
on date of admission→ hospital won’t get reimbursed
6. Research → is carried out through patient records; helps assure research outcomes
are valid and reliable
7. Education → educational information that allows students to relate patients' signs &
symptoms, interventions, and outcomes
▪Can’t just hand over health care records to patient because they may not understand
them fully, so they must get permission to read them and have a clinical or nurse
supervise them and review it in case they have any questions
Principles of documentation
Handwritten, typed, electronic communication/documentation is a form of written
communication and serves as a permanent record of patient information and care
provided by all members of the healthcare team
1. Confidential: keep information private and legal
▪HIPAA ensures patients have the confidentiality of their health care records - if the
patient didn’t sign to have family members hear information, then the family must leave
when discussing care of plan or results with the patient
▪ALL INFORMATION IS CONFIDENTIAL!
2. Accurate: all information was charted, there are no spelling errors (PROOFREAD),
and correct usage of medical terms
3. Concise and Complete: only use abbreviations commonly accepted and approved,
,▪Abbreviations are not used very often since they are prone to mistakes and
misinterpretation
▪Make sure decimals are in the correct spot, the 0 is before the decimal but NEVER
after a whole number in a decimal
4. Objective: use direct quotes from the patient, no interpretations from the nurse are
included it is only objective data
5. Organized and Timely: decreases the chance of forgetting important information
▪Documentation serves as a permanent record of patient information by all members of
the healthcare team
▪Everything we write in the chart is proof we did it → in a court of law the documentation
is what is looked at
▪Reporting is a form of verbal communication that takes place to show patient care→
should happen face to face so you can ask questions !!
▪ More than 70% of sentinel events occur due to miscommunication
Flow sheets, plans of care, and critical pathways used in patient records.
1. Flow Sheets → vital signs flow sheets, I and O flow sheets
2. Plan of care → must be clearly communicate and documented
3. Critical Pathways→ certain critical things that have to be done for certain diagnosis
frequent occurring conditions with predictable outcomes (stroke, seizure, infection)
▪Ex: a patient who comes in and a stroke must be ruled out, the patient MUST go get a
CT within the first 30 minutes of being there
▪ Ex: if a patient comes in with sepsis, they must get antibiotics within an hour of
admission
, These are clearly outlined in care of plan
Communication tools: SBAR, I PASS THE BATON, CUS, debrief, huddles
1. SBAR: Situation, Background, Assessment, Recommendations
- Reports change in patient status and may be used as a transfer of care
report; Communicate critical information
▪Situation → What is going on? What is happening?
▪Background → What are the circumstances leading up to the situation? Admission
date, diagnosis, baseline information
▪Assessment → What do I think the problem is? What is my assessment?
▪Recommendation → What should we do to correct the problem? Order changes,
referrals, visit or reassessment by provider
2. I PASS the BATON: Introduction, Patient, Assessment, Situation, Safety
concerns, Background, Actions, Timing, Ownership, Next
▪ Comprehensive and much more detailed
3. CUS: Concerned, Uncomfortable, Safety issue
I am concerned; I am uncomfortable; This is a safety issue
▪If you see something is not safe and you are concerned about something,
TeamSTEPPS is supposed to help you and stop the care for the patient
4. Debriefing: used after an event (unexpected) to explore what went well and what
could have been performed better
5. Huddles: held at beginning of the shift to highlight important issues that need attentio
Fluid and Electrolytes & IV Therapy
-
Surgical Nursing II Review| Fortis (Latest
2026/ 2027 Update) 100% Verified
Questions & Answers | Grade A
Communication: Team Documentation & Reporting
-
Purposes of the patient record
1. Assessment → comparison of objective and subjective assessment data gathered
by all team members
2. Care Planning → availability of all assessment data allows nurses to more
accurately develop nursing diagnoses, goals, interventions and evaluation of patient
care
3. Legal Document → can be used to prove or disprove injuries a patient incurred
unintentionally or to implicate or absolve improper care
4. Quality Assurance → determines whether certain care standards were met &
documented
▪Audits of patient records that are included are part of accreditation requirements
▪Constantly revising certain procedures, policies based on EBP (research)
5. Reimbursement → basis for decisions regarding care and subsequent
reimbursement to agency
▪Federal agencies of the state look at documentation for reimbursement eligibility
▪Ex: look to see how many unreported cases of falls or bed sores happened last year
,▪Ex: if patient develops bed sore and no one checks it or 48 hours, then the nurse
notices it and says “Yeah she had that when they came in” but it was never documented
on date of admission→ hospital won’t get reimbursed
6. Research → is carried out through patient records; helps assure research outcomes
are valid and reliable
7. Education → educational information that allows students to relate patients' signs &
symptoms, interventions, and outcomes
▪Can’t just hand over health care records to patient because they may not understand
them fully, so they must get permission to read them and have a clinical or nurse
supervise them and review it in case they have any questions
Principles of documentation
Handwritten, typed, electronic communication/documentation is a form of written
communication and serves as a permanent record of patient information and care
provided by all members of the healthcare team
1. Confidential: keep information private and legal
▪HIPAA ensures patients have the confidentiality of their health care records - if the
patient didn’t sign to have family members hear information, then the family must leave
when discussing care of plan or results with the patient
▪ALL INFORMATION IS CONFIDENTIAL!
2. Accurate: all information was charted, there are no spelling errors (PROOFREAD),
and correct usage of medical terms
3. Concise and Complete: only use abbreviations commonly accepted and approved,
,▪Abbreviations are not used very often since they are prone to mistakes and
misinterpretation
▪Make sure decimals are in the correct spot, the 0 is before the decimal but NEVER
after a whole number in a decimal
4. Objective: use direct quotes from the patient, no interpretations from the nurse are
included it is only objective data
5. Organized and Timely: decreases the chance of forgetting important information
▪Documentation serves as a permanent record of patient information by all members of
the healthcare team
▪Everything we write in the chart is proof we did it → in a court of law the documentation
is what is looked at
▪Reporting is a form of verbal communication that takes place to show patient care→
should happen face to face so you can ask questions !!
▪ More than 70% of sentinel events occur due to miscommunication
Flow sheets, plans of care, and critical pathways used in patient records.
1. Flow Sheets → vital signs flow sheets, I and O flow sheets
2. Plan of care → must be clearly communicate and documented
3. Critical Pathways→ certain critical things that have to be done for certain diagnosis
frequent occurring conditions with predictable outcomes (stroke, seizure, infection)
▪Ex: a patient who comes in and a stroke must be ruled out, the patient MUST go get a
CT within the first 30 minutes of being there
▪ Ex: if a patient comes in with sepsis, they must get antibiotics within an hour of
admission
, These are clearly outlined in care of plan
Communication tools: SBAR, I PASS THE BATON, CUS, debrief, huddles
1. SBAR: Situation, Background, Assessment, Recommendations
- Reports change in patient status and may be used as a transfer of care
report; Communicate critical information
▪Situation → What is going on? What is happening?
▪Background → What are the circumstances leading up to the situation? Admission
date, diagnosis, baseline information
▪Assessment → What do I think the problem is? What is my assessment?
▪Recommendation → What should we do to correct the problem? Order changes,
referrals, visit or reassessment by provider
2. I PASS the BATON: Introduction, Patient, Assessment, Situation, Safety
concerns, Background, Actions, Timing, Ownership, Next
▪ Comprehensive and much more detailed
3. CUS: Concerned, Uncomfortable, Safety issue
I am concerned; I am uncomfortable; This is a safety issue
▪If you see something is not safe and you are concerned about something,
TeamSTEPPS is supposed to help you and stop the care for the patient
4. Debriefing: used after an event (unexpected) to explore what went well and what
could have been performed better
5. Huddles: held at beginning of the shift to highlight important issues that need attentio
Fluid and Electrolytes & IV Therapy
-
