OTC LPN 2025 Fundamentals of
Nursing I (Documentation) fully solved
PHI - correct answer ✔✔Protected Health Information
Charting by exception (CBE) - correct answer ✔✔shorthand method for documenting patient
data that is based on well-defined standards of practice; only exceptions to these standards are
documented in narrative notes
Confidentiality - correct answer ✔✔the act of holding information in confidence, not to be
released to unauthorized individuals
JCAHO (Joint Commission on Accreditation of Healthcare Organizations) - correct answer
✔✔The nonprofit organization that inspects healthcare facilities and ensures that standards are
being met.
HIPPA (Health Insurance Portability and Accountability Act) - correct answer ✔✔a federal law
that sets standards for protecting the privacy of patients' health information
subjective data - correct answer ✔✔things a person tells you about that you cannot observe
through your senses; symptoms
objective data - correct answer ✔✔information that is seen, heard, felt, or smelled by an
observer; signs
Validation - correct answer ✔✔act of confirming or verifying
, Source-Oriented Medical Record (SOMR) - correct answer ✔✔a type of patient chart record
keeping that includes separate sections for different sources of patient information, such as
laboratory reports, pathology reports, and progress notes.
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
Focus charting - correct answer ✔✔a documentation system that replaces the problem list with
a focus column that incorporates many aspects of a patient and patient care; the focus may be a
patient strength or a problem or need; the narrative portion of focus charting uses the data (D),
action (A), response (R) format
Narrative charting - correct answer ✔✔a descriptive record of client data and nursing
interventions, written in sentences and paragraphs
Incident reports (unusual occurrences) - correct answer ✔✔-important part of a facility's quality
improvement plan
-examples of incidence include med errors, falls, and needle sticks
-facts documented without judgment or opinion
-should not be referred to in client's medical record
Quality Assurance (QA) - correct answer ✔✔gathering and evaluating information about the
services provided as well as the results achieved and comparing this information with an
accepted standard
permanance - correct answer ✔✔the state or quality of lasting or remaining unchanged
indefinitely.
Nursing I (Documentation) fully solved
PHI - correct answer ✔✔Protected Health Information
Charting by exception (CBE) - correct answer ✔✔shorthand method for documenting patient
data that is based on well-defined standards of practice; only exceptions to these standards are
documented in narrative notes
Confidentiality - correct answer ✔✔the act of holding information in confidence, not to be
released to unauthorized individuals
JCAHO (Joint Commission on Accreditation of Healthcare Organizations) - correct answer
✔✔The nonprofit organization that inspects healthcare facilities and ensures that standards are
being met.
HIPPA (Health Insurance Portability and Accountability Act) - correct answer ✔✔a federal law
that sets standards for protecting the privacy of patients' health information
subjective data - correct answer ✔✔things a person tells you about that you cannot observe
through your senses; symptoms
objective data - correct answer ✔✔information that is seen, heard, felt, or smelled by an
observer; signs
Validation - correct answer ✔✔act of confirming or verifying
, Source-Oriented Medical Record (SOMR) - correct answer ✔✔a type of patient chart record
keeping that includes separate sections for different sources of patient information, such as
laboratory reports, pathology reports, and progress notes.
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
Focus charting - correct answer ✔✔a documentation system that replaces the problem list with
a focus column that incorporates many aspects of a patient and patient care; the focus may be a
patient strength or a problem or need; the narrative portion of focus charting uses the data (D),
action (A), response (R) format
Narrative charting - correct answer ✔✔a descriptive record of client data and nursing
interventions, written in sentences and paragraphs
Incident reports (unusual occurrences) - correct answer ✔✔-important part of a facility's quality
improvement plan
-examples of incidence include med errors, falls, and needle sticks
-facts documented without judgment or opinion
-should not be referred to in client's medical record
Quality Assurance (QA) - correct answer ✔✔gathering and evaluating information about the
services provided as well as the results achieved and comparing this information with an
accepted standard
permanance - correct answer ✔✔the state or quality of lasting or remaining unchanged
indefinitely.
