EXAM 2 CHAPTER 26 DOCUMENTATION AND
INFORMATICS QUESTIONS WITH 100% RATED
ANSWERS 2025/2026 LATEST UPDATE/GET A+
A client sustains an injury from a fall while on a hospital unit. The nurse makes an
incident report. What is the purpose of the incident report? Select all that apply.
1. This report helps in identifying loopholes in the operation of the health care system.
2. This report helps in providing good quality health care.
3. This report helps in negative feedback of the client related to health care delivered.
4. This report helps to determine the severity of the punishment to be delivered.
5. This report helps to identify the need to change a procedure or policy - 1. This report
helps in identifying loopholes in the operation of the health care system.
2. This report helps in providing good quality health care.
5. This report helps to identify the need to change a procedure or policy
The report is a description of an incident such as a fall causing injury. Analysis of the
incident or an occurrence report helps to identify the trends of the system or unit
operation of the health care system. This helps in quality improvement. It helps to
identify the need to change procedures, services, or the infrastructure of a health care
facility. It is an important part of the quality improvement program. The negative
feedback of the client regarding health care delivery is not recorded in the incident
report. The incident report is not used to determine the severity of punishment to be
applied to the person who is responsible for that incident.
Text Reference - p. 358
A client is diagnosed with acute renal failure due to diabetes. Following treatment, the
client recovers. The client is being discharged to home on insulin. The nurse is
preparing a discharge summary for the client. What information should the nurse
provide in the discharge summary? Select all that apply.
1. Entire biographical information of the client
2. Contact information of the health care provider
3. Step-by-step instructions for self-administration of insulin
4. Investigation procedures performed during the period of hospitalization
, 5. Signs and symptoms that have to be reported to the health care provider - 2. Contact
information of the health care provider
3. Step-by-step instructions for self-administration of insulin
5. Signs and symptoms that have to be reported to the health care provider
A proper discharge planning is important to prepare clients for an effective and timely
discharge from a health care institution. This is required for cost savings and ensuring
reimbursement. Contact information of the health care providers is documented to help
the clients contact them when needed. Step-by-step instructions about the procedures
should be provided so that the client can refer to them while doing self-care procedures.
Warning signs and symptoms that require the health care providers' attention should be
documented in the discharge summary. Detailed biographical information of the client
and all the investigations done during the period of hospitalization are not required to be
documented in a discharge summary.
The nurse is learning about Subjective-Objective-Assessment-Plan (SOAP) charting. In
which ways does SOAP charting differ from Problem-Intervention-Evaluation (PIE)
charting? Select all that apply.
1 SOAP charting originates from medical records.
2 SOAP charting is based on a client's problems.
3 SOAP charting includes assessment information.
4 SOAP charting has the notes numbered based on the client's problems identified.
5 SOAP charting is structured into various sections. - 1 SOAP charting originates from
medical records.
3 SOAP charting includes assessment information.
SOAP charting originates from medical records, whereas PIE charting has a nursing
origin. The SOAP chart includes both types of assessment data: subjective and
objective. The PIE chart does not include assessment data. A nurse's daily assessment
data is charted on a separate sheet. Both the chart forms are based on client's
problems. Both chart type have notes numbered based on client's problems. Both the
charts are structures into various sections.
Text Reference - p. 354
The nurse caring for a client in a home care setting needs detailed documentation.
What are the purposes of the documentation? Select all that apply.
INFORMATICS QUESTIONS WITH 100% RATED
ANSWERS 2025/2026 LATEST UPDATE/GET A+
A client sustains an injury from a fall while on a hospital unit. The nurse makes an
incident report. What is the purpose of the incident report? Select all that apply.
1. This report helps in identifying loopholes in the operation of the health care system.
2. This report helps in providing good quality health care.
3. This report helps in negative feedback of the client related to health care delivered.
4. This report helps to determine the severity of the punishment to be delivered.
5. This report helps to identify the need to change a procedure or policy - 1. This report
helps in identifying loopholes in the operation of the health care system.
2. This report helps in providing good quality health care.
5. This report helps to identify the need to change a procedure or policy
The report is a description of an incident such as a fall causing injury. Analysis of the
incident or an occurrence report helps to identify the trends of the system or unit
operation of the health care system. This helps in quality improvement. It helps to
identify the need to change procedures, services, or the infrastructure of a health care
facility. It is an important part of the quality improvement program. The negative
feedback of the client regarding health care delivery is not recorded in the incident
report. The incident report is not used to determine the severity of punishment to be
applied to the person who is responsible for that incident.
Text Reference - p. 358
A client is diagnosed with acute renal failure due to diabetes. Following treatment, the
client recovers. The client is being discharged to home on insulin. The nurse is
preparing a discharge summary for the client. What information should the nurse
provide in the discharge summary? Select all that apply.
1. Entire biographical information of the client
2. Contact information of the health care provider
3. Step-by-step instructions for self-administration of insulin
4. Investigation procedures performed during the period of hospitalization
, 5. Signs and symptoms that have to be reported to the health care provider - 2. Contact
information of the health care provider
3. Step-by-step instructions for self-administration of insulin
5. Signs and symptoms that have to be reported to the health care provider
A proper discharge planning is important to prepare clients for an effective and timely
discharge from a health care institution. This is required for cost savings and ensuring
reimbursement. Contact information of the health care providers is documented to help
the clients contact them when needed. Step-by-step instructions about the procedures
should be provided so that the client can refer to them while doing self-care procedures.
Warning signs and symptoms that require the health care providers' attention should be
documented in the discharge summary. Detailed biographical information of the client
and all the investigations done during the period of hospitalization are not required to be
documented in a discharge summary.
The nurse is learning about Subjective-Objective-Assessment-Plan (SOAP) charting. In
which ways does SOAP charting differ from Problem-Intervention-Evaluation (PIE)
charting? Select all that apply.
1 SOAP charting originates from medical records.
2 SOAP charting is based on a client's problems.
3 SOAP charting includes assessment information.
4 SOAP charting has the notes numbered based on the client's problems identified.
5 SOAP charting is structured into various sections. - 1 SOAP charting originates from
medical records.
3 SOAP charting includes assessment information.
SOAP charting originates from medical records, whereas PIE charting has a nursing
origin. The SOAP chart includes both types of assessment data: subjective and
objective. The PIE chart does not include assessment data. A nurse's daily assessment
data is charted on a separate sheet. Both the chart forms are based on client's
problems. Both chart type have notes numbered based on client's problems. Both the
charts are structures into various sections.
Text Reference - p. 354
The nurse caring for a client in a home care setting needs detailed documentation.
What are the purposes of the documentation? Select all that apply.
