©BRIGHTSTARS 2024/2025 ALL RIGHTS RESERVED.
NURSING DOCUMENTATION/ reporting-
foundations chesp Exam Questions And
Answers 100% Guaranteed Pass.
What is the general determination if something is not charted? - Answer✔it has not been done
even if there are witnesses that it happened
When should the nurse check on a patient after administering a drug for the first time? -
Answer✔one-half hour after the drug administration
where should the nurse chart when administering a narcotic? - Answer✔on the MAR (time and
initials); narcotic sign out sheet and in nurses' notes (need for med, administration site and follow
up for effectiveness of med
What is subjective data? - Answer✔what the patient states or feels e.g. "I have a headache."
What is objective data - Answer✔what the nurse can observe or measure and factually describe
what does SOAPE stand for? - Answer✔Problem oriented record: S-subjective; O-objective; A-
assessment; P-plan; E-evaluation
what does DARE stand for? - Answer✔focus charting: D-subjective and objective data; A-
action; R-response; E-education/patient teaching
what are the five basic reasons for a written patient record? - Answer✔communication;
accountability; legal record of care; teaching; research and data collection; insurance
reimbursement
what parts of the chart are allowed in court? - Answer✔the entire chart is admissible in court
if the MD is called, what documents need to be completed? - Answer✔reason for call and follow
up; MAR or treatment record if an order was given; physician order sheet or phone order form as
appropriate
what basic information is recorded in the nurses' notes? - Answer✔patient's condition, problem
and complaints; interventions; response to interventions; achievement of outcomes
what abbreviations can be used when charting? - Answer✔only those approved by the
institution's written policy
1|Page
, ©BRIGHTSTARS 2024/2025 ALL RIGHTS RESERVED.
what should the nurse do if an error is made? - Answer✔draw one line through the incorrect
word or words; write the correct word above the line with the nurse's initials
can blank spaces be left when charting? - Answer✔never leave blank spaces when charting
when should the nurse chart? - Answer✔as soon and as often as is prudently possible
who is the primary source of information about a patient? - Answer✔the patient
what are the secondary sources of patient data? - Answer✔family members, significant others,
medical records, diagnostic procedures, other care team professionals and nursing literature
when something unusual happens, what should be charted about it? - Answer✔time the problem
occurred; action to deal with the problem; response of MD if called; response of the patient to
any interventions
when can a nurse access a patient's chart or other written information about a particular patient? -
Answer✔only when he/she is clinically involved in that patient's care
when can a nurse divulge information to another staff member? - Answer✔only when that staff
member is involve in that patient's care and needs the information
can a nurse locate a patient's chart using only the room number? - Answer✔no - patients may
have been moved or the chart placed in the wrong slot
who sets standards of care? - Answer✔they are derived from federal and state laws, and
regulations and codes governing nurses and other professionals e.g. the American Nurses Assoc.
and JCAHO (Joint Commission on Hospital Accreditation)
what is the purpose of standards of care? - Answer✔they insure the quality of care given to
patients
what is important in good documentation? - Answer✔legibility, accuracy, correct spelling,
grammar and punctuation
what is narrative charting? - Answer✔sequentially telling the story of that patient for that shift
what are the disadvantages of using a computer to document? - Answer✔cost of equipment, staff
training and security of patient information
what are the advantages of computer documentation? - Answer✔safer due to better legibility,
ease of access by several care givers,
if a patient describes pain in a specific way, how should that be charted? - Answer✔exactly in
the words the patient used with quotation marks around the patient's words
in the soapier charting method, what do the I, E and R stand for? - Answer✔I-intervention; E-
evaluation; R-revision
when using computer documentation, which process does the nurse use to be sure no one else
alters the information the nurse entered? - Answer✔logging off
2|Page
NURSING DOCUMENTATION/ reporting-
foundations chesp Exam Questions And
Answers 100% Guaranteed Pass.
What is the general determination if something is not charted? - Answer✔it has not been done
even if there are witnesses that it happened
When should the nurse check on a patient after administering a drug for the first time? -
Answer✔one-half hour after the drug administration
where should the nurse chart when administering a narcotic? - Answer✔on the MAR (time and
initials); narcotic sign out sheet and in nurses' notes (need for med, administration site and follow
up for effectiveness of med
What is subjective data? - Answer✔what the patient states or feels e.g. "I have a headache."
What is objective data - Answer✔what the nurse can observe or measure and factually describe
what does SOAPE stand for? - Answer✔Problem oriented record: S-subjective; O-objective; A-
assessment; P-plan; E-evaluation
what does DARE stand for? - Answer✔focus charting: D-subjective and objective data; A-
action; R-response; E-education/patient teaching
what are the five basic reasons for a written patient record? - Answer✔communication;
accountability; legal record of care; teaching; research and data collection; insurance
reimbursement
what parts of the chart are allowed in court? - Answer✔the entire chart is admissible in court
if the MD is called, what documents need to be completed? - Answer✔reason for call and follow
up; MAR or treatment record if an order was given; physician order sheet or phone order form as
appropriate
what basic information is recorded in the nurses' notes? - Answer✔patient's condition, problem
and complaints; interventions; response to interventions; achievement of outcomes
what abbreviations can be used when charting? - Answer✔only those approved by the
institution's written policy
1|Page
, ©BRIGHTSTARS 2024/2025 ALL RIGHTS RESERVED.
what should the nurse do if an error is made? - Answer✔draw one line through the incorrect
word or words; write the correct word above the line with the nurse's initials
can blank spaces be left when charting? - Answer✔never leave blank spaces when charting
when should the nurse chart? - Answer✔as soon and as often as is prudently possible
who is the primary source of information about a patient? - Answer✔the patient
what are the secondary sources of patient data? - Answer✔family members, significant others,
medical records, diagnostic procedures, other care team professionals and nursing literature
when something unusual happens, what should be charted about it? - Answer✔time the problem
occurred; action to deal with the problem; response of MD if called; response of the patient to
any interventions
when can a nurse access a patient's chart or other written information about a particular patient? -
Answer✔only when he/she is clinically involved in that patient's care
when can a nurse divulge information to another staff member? - Answer✔only when that staff
member is involve in that patient's care and needs the information
can a nurse locate a patient's chart using only the room number? - Answer✔no - patients may
have been moved or the chart placed in the wrong slot
who sets standards of care? - Answer✔they are derived from federal and state laws, and
regulations and codes governing nurses and other professionals e.g. the American Nurses Assoc.
and JCAHO (Joint Commission on Hospital Accreditation)
what is the purpose of standards of care? - Answer✔they insure the quality of care given to
patients
what is important in good documentation? - Answer✔legibility, accuracy, correct spelling,
grammar and punctuation
what is narrative charting? - Answer✔sequentially telling the story of that patient for that shift
what are the disadvantages of using a computer to document? - Answer✔cost of equipment, staff
training and security of patient information
what are the advantages of computer documentation? - Answer✔safer due to better legibility,
ease of access by several care givers,
if a patient describes pain in a specific way, how should that be charted? - Answer✔exactly in
the words the patient used with quotation marks around the patient's words
in the soapier charting method, what do the I, E and R stand for? - Answer✔I-intervention; E-
evaluation; R-revision
when using computer documentation, which process does the nurse use to be sure no one else
alters the information the nurse entered? - Answer✔logging off
2|Page
