INTEGRATED NURSING PRACTICE
MIDTERM EXAM WITH 100%
CORRECT ANSWERS 2025/2026
Health Care Documentation correct answers >> Any written
or electronically generated information about a patient
Infomatics correct answers >> the property and structure of
information or data
Nursing Documentation correct answers >> ensures
continuity of care; provides legal evidence; evaluate patient
outcomes
patient-centered care documentation correct answers >>
thorough documentation is central to; a nurse is responsible for
documentation detailed information about care provided; the
record serves as a mans of communication among team
members; entries include information about patient status,
interventions delivered patient responses and other critical
information.
documentation safety correct answers >> standards are
integrated into documentation system to ensure care is
delivered_____________; information must be accurate thorough
and current.
,Electronic Health Record (EHR) correct answers >> a
computerized lifelong health care record for an individual that
incorporates data from providers who treat the individual
evidence-based practice correct answers >> clinical decision
making that integrates the best available research with clinical
expertise and patient characteristics and preferences
Confidentiality correct answers >> the act of holding
information in confidence, not to be released to unauthorized
individuals
Legal guidelines of documentation correct answers >> -begin
each entry with date & time
-legible and in black, non-erasable ink
-no white out or blackened out errors
-info inadvertently omitted may be added as a "late entry"
-signed with signature of person making entry and dated
-should reflect assessments, interventions, and evaluations
Documentation standards correct answers >> Within the
context of healthcare, describe those principles, codes, beliefs,
guidelines, and regulations that guide health record
documentation
objective correct answers >> Factual, related to reality or
physical objects; not influenced by emotions, unbiased
, subjective correct answers >> Existing in the mind or
relating to one's own thoughts, opinions, emotions, etc.; personal,
individual, based on feelings
Accurate documentation correct answers >> clear, concise,
objective (nonjudgmental), and correct
Complete documentation correct answers >> the information
within a recorded entry or a report must be complete, containing
appropriate and essential information; patient response
Current documentation correct answers >> timely entries
document at time of occurrence
four p's of care correct answers >> Pain, position,
possessions & potty
activities when they occur correct answers >> document -
acute change in medical condition, pain assessment,
administration of medication or treatment, preparations for
diagnostic tests or surgery, patient response to an intervention
and admissions, transfer, discharge, or death of a patient
Methods of Recording correct answers >> Problem-Oriented
medical record (POMR)
Source records
Charting by exception (CBE)
Situation background assessment and recommendation (SBAR)
MIDTERM EXAM WITH 100%
CORRECT ANSWERS 2025/2026
Health Care Documentation correct answers >> Any written
or electronically generated information about a patient
Infomatics correct answers >> the property and structure of
information or data
Nursing Documentation correct answers >> ensures
continuity of care; provides legal evidence; evaluate patient
outcomes
patient-centered care documentation correct answers >>
thorough documentation is central to; a nurse is responsible for
documentation detailed information about care provided; the
record serves as a mans of communication among team
members; entries include information about patient status,
interventions delivered patient responses and other critical
information.
documentation safety correct answers >> standards are
integrated into documentation system to ensure care is
delivered_____________; information must be accurate thorough
and current.
,Electronic Health Record (EHR) correct answers >> a
computerized lifelong health care record for an individual that
incorporates data from providers who treat the individual
evidence-based practice correct answers >> clinical decision
making that integrates the best available research with clinical
expertise and patient characteristics and preferences
Confidentiality correct answers >> the act of holding
information in confidence, not to be released to unauthorized
individuals
Legal guidelines of documentation correct answers >> -begin
each entry with date & time
-legible and in black, non-erasable ink
-no white out or blackened out errors
-info inadvertently omitted may be added as a "late entry"
-signed with signature of person making entry and dated
-should reflect assessments, interventions, and evaluations
Documentation standards correct answers >> Within the
context of healthcare, describe those principles, codes, beliefs,
guidelines, and regulations that guide health record
documentation
objective correct answers >> Factual, related to reality or
physical objects; not influenced by emotions, unbiased
, subjective correct answers >> Existing in the mind or
relating to one's own thoughts, opinions, emotions, etc.; personal,
individual, based on feelings
Accurate documentation correct answers >> clear, concise,
objective (nonjudgmental), and correct
Complete documentation correct answers >> the information
within a recorded entry or a report must be complete, containing
appropriate and essential information; patient response
Current documentation correct answers >> timely entries
document at time of occurrence
four p's of care correct answers >> Pain, position,
possessions & potty
activities when they occur correct answers >> document -
acute change in medical condition, pain assessment,
administration of medication or treatment, preparations for
diagnostic tests or surgery, patient response to an intervention
and admissions, transfer, discharge, or death of a patient
Methods of Recording correct answers >> Problem-Oriented
medical record (POMR)
Source records
Charting by exception (CBE)
Situation background assessment and recommendation (SBAR)
