NUR209/ NUR 209 Exam 2 Study guide
(Latest 2025/ 2026 Update) Medical Surgical
Nursing II| Questions and Verified Answers|
100% Correct| Grade A – Fortis
Purposes of the patient record
1. Assessment → comparison of objective and subjective assessment data gathered
by all team members
2. Care Planning → availability of all assessment data allows nurses to more
accurately develop nursing diagnoses, goals, interventions and evaluation of
patient care
3. Legal Document → can be used to prove or disprove injuries a patient incurred
unintentionally or to implicate or absolve improper care
4. Quality Assurance → determines whether certain care standards were met &
documented
▪ Audits of patient records that are included are part of accreditation requirements
▪ Constantly revising certain procedures, policies based on EBP (research)
5. Reimbursement → basis for decisions regarding care and subsequent
reimbursement to agency
▪ Federal agencies of the state look at documentation for reimbursement eligibility
▪ Ex: look to see how many unreported cases of falls or bed sores happened last
year
, NUR209/ NUR 209 Exam 2 Study guide
(Latest 2025/ 2026 Update) Medical Surgical
Nursing II| Questions and Verified Answers|
100% Correct| Grade A – Fortis
▪ Ex: if patient develops bed sore and no one checks it or 48 hours, then the nurse
notices it and says "Yeah she had that when they came in" but it was never
documented on date of admission→ hospital won't get reimbursed
6. Research → is carried out through patient records; helps assure research
outcomes are valid and reliable
7. Education → educational information that allows students to relate patients'
signs & symptoms, interventions, and outcomes
▪ Can't just hand over health care records to patient because they may not
understand them fully, so they must get permission to read them and have a clinical
or nurse supervise them and review it in case they have any questions
Principles of documentation
Handwritten, typed, electronic communication/documentation is a form of written
communication and serves as a permanent record of patient information and care
provided by all members of the healthcare team
1. Confidential: keep information private and legal
▪ HIPAA ensures patients have the confidentiality of their health care records - if
the patient didn't sign to have family members hear information, then the family
must leave when discussing care of plan or results with the patient
▪ ALL INFORMATION IS CONFIDENTIAL!
(Latest 2025/ 2026 Update) Medical Surgical
Nursing II| Questions and Verified Answers|
100% Correct| Grade A – Fortis
Purposes of the patient record
1. Assessment → comparison of objective and subjective assessment data gathered
by all team members
2. Care Planning → availability of all assessment data allows nurses to more
accurately develop nursing diagnoses, goals, interventions and evaluation of
patient care
3. Legal Document → can be used to prove or disprove injuries a patient incurred
unintentionally or to implicate or absolve improper care
4. Quality Assurance → determines whether certain care standards were met &
documented
▪ Audits of patient records that are included are part of accreditation requirements
▪ Constantly revising certain procedures, policies based on EBP (research)
5. Reimbursement → basis for decisions regarding care and subsequent
reimbursement to agency
▪ Federal agencies of the state look at documentation for reimbursement eligibility
▪ Ex: look to see how many unreported cases of falls or bed sores happened last
year
, NUR209/ NUR 209 Exam 2 Study guide
(Latest 2025/ 2026 Update) Medical Surgical
Nursing II| Questions and Verified Answers|
100% Correct| Grade A – Fortis
▪ Ex: if patient develops bed sore and no one checks it or 48 hours, then the nurse
notices it and says "Yeah she had that when they came in" but it was never
documented on date of admission→ hospital won't get reimbursed
6. Research → is carried out through patient records; helps assure research
outcomes are valid and reliable
7. Education → educational information that allows students to relate patients'
signs & symptoms, interventions, and outcomes
▪ Can't just hand over health care records to patient because they may not
understand them fully, so they must get permission to read them and have a clinical
or nurse supervise them and review it in case they have any questions
Principles of documentation
Handwritten, typed, electronic communication/documentation is a form of written
communication and serves as a permanent record of patient information and care
provided by all members of the healthcare team
1. Confidential: keep information private and legal
▪ HIPAA ensures patients have the confidentiality of their health care records - if
the patient didn't sign to have family members hear information, then the family
must leave when discussing care of plan or results with the patient
▪ ALL INFORMATION IS CONFIDENTIAL!
