1
NR 569
NR 569/ NR569 MIDTERM EXAM: DIFFERENTIAL
DIAGNOSIS IN ACUTE CARE | QS & AS| GRADE A|
(NEW 2026/ 2027) CHAMBERLAIN
What is the difference between subjective and objective data in patient
assessments? - ANS ✓Subjective data is reported by the patient (SELF),
while objective data is observed through physical assessment and labs.
What is the significance of creating a differential diagnosis? - ANS ✓It
involves using clinical reasoning to distinguish between two or more
conditions that share similar signs and symptoms.
What are pertinent negatives in medical documentation? - ANS ✓Signs and
symptoms that are NOT present but would be expected, which can weaken
a diagnosis.
What are pertinent positives in medical documentation? - ANS ✓Signs and
symptoms that are present and expected, which support a diagnosis.
What is the first principle of good documentation regarding organization? -
ANS ✓Ensure clear organization with headings, indentations, and spacing.
How should the history of present illness (HPI) be arranged in
documentation? - ANS ✓In chronological order, starting with the current
episode and then providing relevant background information.
NR 569
, 2
NR 569
What should be included in the assessment section of documentation? -
ANS ✓Supporting evidence for each problem or diagnosis, detailing both
positive and negative findings.
Why is it important to describe pertinent negatives specifically? - ANS ✓To
indicate that potential abnormalities were considered and ruled out, such
as absence of injury or bleeding disorders.
What should be avoided in medical documentation? - ANS
✓Overgeneralizations or omissions of important data, as any unrecorded
information is lost.
What is the guideline regarding excessive detail in documentation? - ANS
✓Descriptions should be concise, omitting unimportant structures that do
not contribute to the assessment.
What should be the focus when documenting negative findings in a
patient's record? - ANS ✓Concentrate on major negative findings relevant to
the patient's complaints, such as 'no heart murmurs'.
How should the written style of medical documentation be characterized? -
ANS ✓It should be succinct, using phrases, short words, and abbreviations
appropriately, avoiding unnecessary repetition.
What is the recommended unit of measurement for findings in medical
documentation? - ANS ✓Measurements should be in centimeters, not in
terms of fruits, nuts, or vegetables.
NR 569
NR 569
NR 569/ NR569 MIDTERM EXAM: DIFFERENTIAL
DIAGNOSIS IN ACUTE CARE | QS & AS| GRADE A|
(NEW 2026/ 2027) CHAMBERLAIN
What is the difference between subjective and objective data in patient
assessments? - ANS ✓Subjective data is reported by the patient (SELF),
while objective data is observed through physical assessment and labs.
What is the significance of creating a differential diagnosis? - ANS ✓It
involves using clinical reasoning to distinguish between two or more
conditions that share similar signs and symptoms.
What are pertinent negatives in medical documentation? - ANS ✓Signs and
symptoms that are NOT present but would be expected, which can weaken
a diagnosis.
What are pertinent positives in medical documentation? - ANS ✓Signs and
symptoms that are present and expected, which support a diagnosis.
What is the first principle of good documentation regarding organization? -
ANS ✓Ensure clear organization with headings, indentations, and spacing.
How should the history of present illness (HPI) be arranged in
documentation? - ANS ✓In chronological order, starting with the current
episode and then providing relevant background information.
NR 569
, 2
NR 569
What should be included in the assessment section of documentation? -
ANS ✓Supporting evidence for each problem or diagnosis, detailing both
positive and negative findings.
Why is it important to describe pertinent negatives specifically? - ANS ✓To
indicate that potential abnormalities were considered and ruled out, such
as absence of injury or bleeding disorders.
What should be avoided in medical documentation? - ANS
✓Overgeneralizations or omissions of important data, as any unrecorded
information is lost.
What is the guideline regarding excessive detail in documentation? - ANS
✓Descriptions should be concise, omitting unimportant structures that do
not contribute to the assessment.
What should be the focus when documenting negative findings in a
patient's record? - ANS ✓Concentrate on major negative findings relevant to
the patient's complaints, such as 'no heart murmurs'.
How should the written style of medical documentation be characterized? -
ANS ✓It should be succinct, using phrases, short words, and abbreviations
appropriately, avoiding unnecessary repetition.
What is the recommended unit of measurement for findings in medical
documentation? - ANS ✓Measurements should be in centimeters, not in
terms of fruits, nuts, or vegetables.
NR 569
