TEST BANKS DOCUMENTATION FOR NURSING STUDENT
(2026/2027)
A hospital is not able to be reimbursed for care a particular client received while in the emergency
department. The client came in with chest pain, which was later diagnosed as gastric reflux. A problem
in documentation that may have caused the lack of reimbursement would be which of the following?
1. The clients record contained an incorrect DRG.
2. The client was charged for an ECG.
3. A code cart was opened and the client was charged for medications opened but not used.
4. The physician made a diagnostic mistake.
Correct Answer: 1
Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The
clients clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the
appropriate care has been given. Codable diagnoses, such as DRGs, are supported by accurate, thorough
recording by nurses.
Rationale 2: This would not necessarily result in the problem related to reimbursement since it is a
reasonable diagnostic test to perform in this situation.
Rationale 3: This would not necessarily result in the problem related to reimbursement.
Rationale 4: This would not necessarily result in the problem related to reimbursement.
,The nurse administered analgesic medications to an assigned client via central line. This information
should be documented in which section if using PIE charting?
1. Plan
2. Intervention
3. Evaluation
4. Progress notes
Correct Answer: 2
Rationale 1: The problem statement is labeled P and referred to by number.
Rationale 2: The interventions employed to manage the problem are labeled I and numbered according
to the problem.
Rationale 3: The E is evaluation of the effectiveness of the intervention and is also labeled and
numbered according to the problem..
Rationale 4: Progress notes are not part of the identified labels of PIE charting.
A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with
them, since its his record. The nurse responds correctly by saying:
,1. Youll have to ask your doctor for permission to do that.
2. Actually, the original record is the property of the hospital, but you are welcome to copies of your
records.
3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have
to worry about those details.
4. Theres a new law that protects your records, so youre not going to be able to have access to them.
Correct Answer: 2
Rationale 1: The doctors permission is not a requirement for the release of a clients medical record.
Rationale 2: Although the clients record is protected legally as private, access to the record is restricted
to health professionals involved in the clients care. The institution or agency is the rightful owner of the
clients record, but the client has the right to access all information contained within his own record and
to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The
Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health
information and maintain confidentiality of client records.
Rationale 3: The client does have a legal right concerning his medical record so this option doesnt
adequately address his question.
Rationale 4: This option is not correct, the client does have a legal right to access his medical records.
, After classroom discussion regarding confidentiality policies and laws protecting client records, a student
asks why its permissible for them to review and have access to client records in the clinical area. The
nurse educator responds correctly by stating that:
1. Confidentiality and privacy laws dont apply to students.
2. Most students review so many records and charts that they could not possibly remember details from
any one of them.
3. Records are used in educational settings and for learning purposes, but the student is bound to hold
all information in strict confidence.
4. As long as the clinical instructor is in the area, accessing client records is part of the education
process.
Correct Answer: 3
Rationale 1: This option is not correct, the laws do apply to students.
Rationale 2: While this may or may not be a true statement it is not an appropriate response to the
students question.
Rationale 3: For purposes of education and research, most agencies allow students and graduate health
professionals access to client records. The student or graduate is bound by a strict ethical code and legal
responsibility to hold all information in confidence. It is the responsibility of the student or health
professional to protect the clients privacy by not using a name or any statements in the notations that
would identify the client.
Rationale 4: While this is true it should not imply that the laws of confidentiality dont apply to students.
(2026/2027)
A hospital is not able to be reimbursed for care a particular client received while in the emergency
department. The client came in with chest pain, which was later diagnosed as gastric reflux. A problem
in documentation that may have caused the lack of reimbursement would be which of the following?
1. The clients record contained an incorrect DRG.
2. The client was charged for an ECG.
3. A code cart was opened and the client was charged for medications opened but not used.
4. The physician made a diagnostic mistake.
Correct Answer: 1
Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The
clients clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the
appropriate care has been given. Codable diagnoses, such as DRGs, are supported by accurate, thorough
recording by nurses.
Rationale 2: This would not necessarily result in the problem related to reimbursement since it is a
reasonable diagnostic test to perform in this situation.
Rationale 3: This would not necessarily result in the problem related to reimbursement.
Rationale 4: This would not necessarily result in the problem related to reimbursement.
,The nurse administered analgesic medications to an assigned client via central line. This information
should be documented in which section if using PIE charting?
1. Plan
2. Intervention
3. Evaluation
4. Progress notes
Correct Answer: 2
Rationale 1: The problem statement is labeled P and referred to by number.
Rationale 2: The interventions employed to manage the problem are labeled I and numbered according
to the problem.
Rationale 3: The E is evaluation of the effectiveness of the intervention and is also labeled and
numbered according to the problem..
Rationale 4: Progress notes are not part of the identified labels of PIE charting.
A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart with
them, since its his record. The nurse responds correctly by saying:
,1. Youll have to ask your doctor for permission to do that.
2. Actually, the original record is the property of the hospital, but you are welcome to copies of your
records.
3. Well make sure that all of your records are sent ahead to the rehab hospital, so you dont really have
to worry about those details.
4. Theres a new law that protects your records, so youre not going to be able to have access to them.
Correct Answer: 2
Rationale 1: The doctors permission is not a requirement for the release of a clients medical record.
Rationale 2: Although the clients record is protected legally as private, access to the record is restricted
to health professionals involved in the clients care. The institution or agency is the rightful owner of the
clients record, but the client has the right to access all information contained within his own record and
to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The
Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health
information and maintain confidentiality of client records.
Rationale 3: The client does have a legal right concerning his medical record so this option doesnt
adequately address his question.
Rationale 4: This option is not correct, the client does have a legal right to access his medical records.
, After classroom discussion regarding confidentiality policies and laws protecting client records, a student
asks why its permissible for them to review and have access to client records in the clinical area. The
nurse educator responds correctly by stating that:
1. Confidentiality and privacy laws dont apply to students.
2. Most students review so many records and charts that they could not possibly remember details from
any one of them.
3. Records are used in educational settings and for learning purposes, but the student is bound to hold
all information in strict confidence.
4. As long as the clinical instructor is in the area, accessing client records is part of the education
process.
Correct Answer: 3
Rationale 1: This option is not correct, the laws do apply to students.
Rationale 2: While this may or may not be a true statement it is not an appropriate response to the
students question.
Rationale 3: For purposes of education and research, most agencies allow students and graduate health
professionals access to client records. The student or graduate is bound by a strict ethical code and legal
responsibility to hold all information in confidence. It is the responsibility of the student or health
professional to protect the clients privacy by not using a name or any statements in the notations that
would identify the client.
Rationale 4: While this is true it should not imply that the laws of confidentiality dont apply to students.
