NR302 DOCUMENTATION QUESTIONS AND
ANSWERS 100% ACCURATE
__ the health assessment is the first step to creating the database of an individual's experience
with a healthcare provider, for it is this data that will inform the decisions made by all
members of the healthcare team. Although the healthcare provider is the leader of the
healthcare team, no single health professional is responsible for the information in the health
record. --Correct Answer--Documenting
When documenting the assessment of the eyes, the nurse forgets the appropriate abbreviation
for normal reaction of the pupils. Which actions are appropriate at this time?
1. Do not chart that portion of the assessment.
2. Write the whole word instead of an abbreviation.
3. Use the first three letters of the word as the abbreviation.
4. Look up the appropriate abbreviation and use it.
5. Just use something close, most medical professionals will know what it is. --Correct
Answer--2
4
While documenting a physical assessment, the nurse realizes they did not check the client's
eyes. What should the nurse do?
, 1. Document normal findings; the client did not tell the nurse anything was wrong with their
eyes.
2. Document something, so it does not look like it was forgotten.
3. Complete the proper assessment and then document.
4. Just skip it; there is probably nothing wrong. --Correct Answer--3
SOAP stands for:
1. Subjective, Official, Assessment, Personal
2. Succinct, Objective, Accurate, Plan
3. Succinct, Official, Assessment, Personal
4. Subjective, Objective, Assessment, Plan --Correct Answer--4
Though the goal of health assessment is the collection of data on which to make decisions for
care, without proper _ of findings by all healthcare team members, it is difficult to provide
coordinated, holistic care. Within the healthcare system, this by health professionals serves a
larger purpose as well. --Correct Answer--DOCUMENTATIONS
- Assess
- Plan
- Implement
- Eval
ANSWERS 100% ACCURATE
__ the health assessment is the first step to creating the database of an individual's experience
with a healthcare provider, for it is this data that will inform the decisions made by all
members of the healthcare team. Although the healthcare provider is the leader of the
healthcare team, no single health professional is responsible for the information in the health
record. --Correct Answer--Documenting
When documenting the assessment of the eyes, the nurse forgets the appropriate abbreviation
for normal reaction of the pupils. Which actions are appropriate at this time?
1. Do not chart that portion of the assessment.
2. Write the whole word instead of an abbreviation.
3. Use the first three letters of the word as the abbreviation.
4. Look up the appropriate abbreviation and use it.
5. Just use something close, most medical professionals will know what it is. --Correct
Answer--2
4
While documenting a physical assessment, the nurse realizes they did not check the client's
eyes. What should the nurse do?
, 1. Document normal findings; the client did not tell the nurse anything was wrong with their
eyes.
2. Document something, so it does not look like it was forgotten.
3. Complete the proper assessment and then document.
4. Just skip it; there is probably nothing wrong. --Correct Answer--3
SOAP stands for:
1. Subjective, Official, Assessment, Personal
2. Succinct, Objective, Accurate, Plan
3. Succinct, Official, Assessment, Personal
4. Subjective, Objective, Assessment, Plan --Correct Answer--4
Though the goal of health assessment is the collection of data on which to make decisions for
care, without proper _ of findings by all healthcare team members, it is difficult to provide
coordinated, holistic care. Within the healthcare system, this by health professionals serves a
larger purpose as well. --Correct Answer--DOCUMENTATIONS
- Assess
- Plan
- Implement
- Eval
