NURS 222 Exam 3 questions with updated answers A+ Grade
2026\2027
medical record
- correct answer a confidential, permanent legal documentation of information relevant to patient's
health care
-treatment received, patient education, continuing status, etc
report
- correct answer oral, written or audiotape exchanges of information between healthcare team
-change of shift, accident, incident
informatics
- correct answer use of information and computer technology to support all aspects of nursing practice
healthcare informatics system
- correct answer group of systems used within a health care organization that support and enhance
health care
administrative information system
- correct answer used to manage the financial, personnel, materials, facilities, and other resources used
in the delivery of healthcare services
-payroll, quality
clinical information systems
- correct answer monitoring systems, order entry, and laboratory, radiology, and pharmacy systems
-EHR/EMR
-CPOE
,computer provider order entry (CPOE)
- correct answer where physicians enter orders electronically
benefits of computerized documentation
- correct answer reduction of errors
standardized nursing care plans
increased nurse productivity
electronic medical record (EMR)
- correct answer patient medical record from a single medical practice, hospital, or pharmacy
-part of EHR
electronic health record (EHR)
- correct answer a computerized lifelong health care record for an individual that incorporates data from
providers who treat the individual
joint commission
- correct answer an independent, not-for-profit organization that evaluates and accredits healthcare
organizations
audits
- correct answer determine if quality standards have been met
care that is undocumented is not _________.
- correct answer done
reimbursement
- correct answer determined by DRGs (diagnostic related groups)
how should you write subjective info on charts?
- correct answer using quotation marks
,military time
- correct answer 24 hr clock
begins at 0001 and ends at 2400
-ex) 11:42 am is 1142 hrs
2:00 pm is 1400 hrs
what time is 7pm military time?
- correct answer 1900 hrs
problem-oriented medical record (POMR)
- correct answer documentation system organized according to the person's specific health problems
-includes database, problem list, plan of care, and progress notes
database (POMR)
- correct answer includes all available assessment information
problem list (POMR)
- correct answer created by members of the health care team after assessment information is analyzed
-can add/remove
-main diagnosis is first
-chronological order
care plan (POMR)
- correct answer for nurses, includes nursing diagnosis, expected outcomes, and interventions
-developed for each member of the health care team
progress notes (POMR)
- correct answer monitor and record progress of patient
narrative documentation
- correct answer records information as a sequence of events in a story-like manner
-traditional method
, -common in emergency situation
SOAP documentation
- correct answer subjective-objective assessment plan
-used by nurse practitioners
PIE documentation
- correct answer problem intervention evaluation
-oriented from problem
-flowsheet for daily assessment
-simplifies documentation
focus charting (DAR)
- correct answer data action response
-incorporates all aspects of the nursing process
-highlights a patient's concerns
-can be integrated into any clinical setting
-signs, symptoms, behavior
-nursing diagnosis
charting by exception
- correct answer reduces time of documenting by check marking info but when things are abnormal it
must be written out to not change in patient condition
benefits of charting by exception
- correct answer easy to track unexpected changes
eliminates repetition and subjective data
decreases time spent on charting
case management
- correct answer model of delivering care that includes a multidisciplinary approach
2026\2027
medical record
- correct answer a confidential, permanent legal documentation of information relevant to patient's
health care
-treatment received, patient education, continuing status, etc
report
- correct answer oral, written or audiotape exchanges of information between healthcare team
-change of shift, accident, incident
informatics
- correct answer use of information and computer technology to support all aspects of nursing practice
healthcare informatics system
- correct answer group of systems used within a health care organization that support and enhance
health care
administrative information system
- correct answer used to manage the financial, personnel, materials, facilities, and other resources used
in the delivery of healthcare services
-payroll, quality
clinical information systems
- correct answer monitoring systems, order entry, and laboratory, radiology, and pharmacy systems
-EHR/EMR
-CPOE
,computer provider order entry (CPOE)
- correct answer where physicians enter orders electronically
benefits of computerized documentation
- correct answer reduction of errors
standardized nursing care plans
increased nurse productivity
electronic medical record (EMR)
- correct answer patient medical record from a single medical practice, hospital, or pharmacy
-part of EHR
electronic health record (EHR)
- correct answer a computerized lifelong health care record for an individual that incorporates data from
providers who treat the individual
joint commission
- correct answer an independent, not-for-profit organization that evaluates and accredits healthcare
organizations
audits
- correct answer determine if quality standards have been met
care that is undocumented is not _________.
- correct answer done
reimbursement
- correct answer determined by DRGs (diagnostic related groups)
how should you write subjective info on charts?
- correct answer using quotation marks
,military time
- correct answer 24 hr clock
begins at 0001 and ends at 2400
-ex) 11:42 am is 1142 hrs
2:00 pm is 1400 hrs
what time is 7pm military time?
- correct answer 1900 hrs
problem-oriented medical record (POMR)
- correct answer documentation system organized according to the person's specific health problems
-includes database, problem list, plan of care, and progress notes
database (POMR)
- correct answer includes all available assessment information
problem list (POMR)
- correct answer created by members of the health care team after assessment information is analyzed
-can add/remove
-main diagnosis is first
-chronological order
care plan (POMR)
- correct answer for nurses, includes nursing diagnosis, expected outcomes, and interventions
-developed for each member of the health care team
progress notes (POMR)
- correct answer monitor and record progress of patient
narrative documentation
- correct answer records information as a sequence of events in a story-like manner
-traditional method
, -common in emergency situation
SOAP documentation
- correct answer subjective-objective assessment plan
-used by nurse practitioners
PIE documentation
- correct answer problem intervention evaluation
-oriented from problem
-flowsheet for daily assessment
-simplifies documentation
focus charting (DAR)
- correct answer data action response
-incorporates all aspects of the nursing process
-highlights a patient's concerns
-can be integrated into any clinical setting
-signs, symptoms, behavior
-nursing diagnosis
charting by exception
- correct answer reduces time of documenting by check marking info but when things are abnormal it
must be written out to not change in patient condition
benefits of charting by exception
- correct answer easy to track unexpected changes
eliminates repetition and subjective data
decreases time spent on charting
case management
- correct answer model of delivering care that includes a multidisciplinary approach
