NSC 232 Final Exam EKU Questions and
Answers 100% Solved | Rated A+
Effective Communication - ✔✔-essential to the coordination and continuity
of care
-enables personnel to support and compliment one another's services
-avoid duplications and omissions of care
Purposes of Documentation - ✔✔-communication
-planning client care
-quality assurance
-research
-education
-reimbursement
-legal documentation
Documentation - ✔✔-is written or typed
-a legal record of all pertinent interactions with a patient
Nursing Process - ✔✔-assessing
-diagnosing
1
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
,-planning
-implementing
-evaluating
Documentation Guidelines: Content - ✔✔-complete, accurate, concise,
factual
-reflecting nursing process
-record observations, not interpretation
-terminology
-sequencing
-include safety precautions
-medical visits, consultations
-document nursing response to questionable medical orders
-avoid use of stereotypes or derogatory terms
Documentation Guidelines: Timing - ✔✔-timely
-include date and time
-24 hour clock
-do not document before carrying out
Documentation Guidelines: Format - ✔✔-correct chart
-appropriate form
-write legibly
2
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
,-use standard terminology
-date and time each entry
-chart interventions chronologically
-use consecutive lines, do not skip lines
Documentation Guidelines: Accountability - ✔✔-sign first name, last name,
title to each entry
-do not use dittos, erasers, correcting fluids, etc.
-identify each page record
-record is permanent
Documentation Guidelines: Confidentiality - ✔✔-patient moral and legal
rights (HIPAA)
Types of Nursing Documentation - ✔✔-admission notes
-change of shift notes
-assessment notes
-interval or progress notes
-transfer and discharge notes
-client teaching notes
What is Documented?? - ✔✔-descriptions of observations
-symptoms and complaints
3
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
, -dressings,tubes, or attached devices
-medications and treatments
-observations of psychosocial status
-activities of daily living
-valuable
-spiritual care
-safety concerns
Documentation Systems - ✔✔-narrative charting
-focus charting
-charting by exception (CBE)
-problem oriented medical record (POMR)
-PIE
-flow sheets
-graphic records
-clinical pathways (care maps)
POMR - ✔✔subjective, objective, assessment, plan
Vital Signs - ✔✔-temperature
-pulse
-respiratory
-blood pressure
4
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
Answers 100% Solved | Rated A+
Effective Communication - ✔✔-essential to the coordination and continuity
of care
-enables personnel to support and compliment one another's services
-avoid duplications and omissions of care
Purposes of Documentation - ✔✔-communication
-planning client care
-quality assurance
-research
-education
-reimbursement
-legal documentation
Documentation - ✔✔-is written or typed
-a legal record of all pertinent interactions with a patient
Nursing Process - ✔✔-assessing
-diagnosing
1
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
,-planning
-implementing
-evaluating
Documentation Guidelines: Content - ✔✔-complete, accurate, concise,
factual
-reflecting nursing process
-record observations, not interpretation
-terminology
-sequencing
-include safety precautions
-medical visits, consultations
-document nursing response to questionable medical orders
-avoid use of stereotypes or derogatory terms
Documentation Guidelines: Timing - ✔✔-timely
-include date and time
-24 hour clock
-do not document before carrying out
Documentation Guidelines: Format - ✔✔-correct chart
-appropriate form
-write legibly
2
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
,-use standard terminology
-date and time each entry
-chart interventions chronologically
-use consecutive lines, do not skip lines
Documentation Guidelines: Accountability - ✔✔-sign first name, last name,
title to each entry
-do not use dittos, erasers, correcting fluids, etc.
-identify each page record
-record is permanent
Documentation Guidelines: Confidentiality - ✔✔-patient moral and legal
rights (HIPAA)
Types of Nursing Documentation - ✔✔-admission notes
-change of shift notes
-assessment notes
-interval or progress notes
-transfer and discharge notes
-client teaching notes
What is Documented?? - ✔✔-descriptions of observations
-symptoms and complaints
3
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
, -dressings,tubes, or attached devices
-medications and treatments
-observations of psychosocial status
-activities of daily living
-valuable
-spiritual care
-safety concerns
Documentation Systems - ✔✔-narrative charting
-focus charting
-charting by exception (CBE)
-problem oriented medical record (POMR)
-PIE
-flow sheets
-graphic records
-clinical pathways (care maps)
POMR - ✔✔subjective, objective, assessment, plan
Vital Signs - ✔✔-temperature
-pulse
-respiratory
-blood pressure
4
©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.
