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NSC 114 Exam 2 Questions and Answers (100%
Correct Answers) Already Graded A+
Giving report or a consult is discussion between Ans: Healthcare workers
Report can be Ans: Oral, written or computer based
The client record is.... Ans: Also called a chart
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Formal legal document that provides evidence of client care
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Written or computer based
The process of making an entry on a chart is called Ans: Recording,
charting or documenting
What day were HIPPA regulations updated Ans: April 14, 2003
What are some ways to ensure confidentiality of computer record? Ans:
Never sharing your password
Never leave the computer unintended
Dont display client information where it can be seen
Shred unneeded papers
Follow procedure for documenting sensitive information
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IT must install firewall to protect from unauthorized access
when it comes to correcting a documenting error you should..... Ans:
Usually strike a single line, but follow your hospital policy
What are the purposes of client record Ans: Communication, in turn
preventing fragmentation, repetition and delays
Planning
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Baseline and ongoing data
Auditing health agencies review client record for quality assurance
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purposes
Research
Treatment plans
What are DRGs? Ans: Diagnostic related guidelines are used to give a
general idea of how long your hospital stay will be
What would a case manager look at when it comes to insurance? Ans:
How many days the client insurance will pay for
The court can pull the client chart for evidence unless Ans: The client
objects because the information is confidential
The source oriented record is Ans: Traditional, narrative charting
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Information about a particular problem is distributed throughout the
record
Each discipline makes notations in a separate section
what is narrative charting Ans: Notes that include routine care, normal
findings, and client problems
Often chronologic
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The problem oriented medical record Ans: Is data arranged according
to client problem
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Health team contributes to the problem list, plan of care and progress
notes
Encourages collaboration
Easier to track the status of problems
What is the data base in the problem oriented medical record Ans: All
information known about the client when the client first enters the health
care agency
what is the problem list the problem oriented medical record Ans: The
NANDAs, listed in order in which they are indentured and others resolved
What is the plan of care in the problem oriented medical record Ans:
Made with reference to active problems
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Generated by individual who lists the problems
What are the progress notes in the problem oriented medical record
Ans: Made by all health care professionals involved in a clients care
Uses SOAP, SOAPIE, and SOAPIER
What does SOAP stand for? Ans: Subjective
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Objective
Assessment
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Plan
What does PIE stand for? Ans: Problems
Interventions
Evaluations
What doe DAR stand for? Ans: Data (assessment)
Action (plan and implementation)
Response (evaluation)
What is focus charting Ans: Focused on client concerns and strengths
Organized in DAR form
1
NSC 114 Exam 2 Questions and Answers (100%
Correct Answers) Already Graded A+
Giving report or a consult is discussion between Ans: Healthcare workers
Report can be Ans: Oral, written or computer based
The client record is.... Ans: Also called a chart
© 2026 Assignment Expert
Formal legal document that provides evidence of client care
Guru01 - Stuvia
Written or computer based
The process of making an entry on a chart is called Ans: Recording,
charting or documenting
What day were HIPPA regulations updated Ans: April 14, 2003
What are some ways to ensure confidentiality of computer record? Ans:
Never sharing your password
Never leave the computer unintended
Dont display client information where it can be seen
Shred unneeded papers
Follow procedure for documenting sensitive information
,For Expert help and assignment handling,
2
IT must install firewall to protect from unauthorized access
when it comes to correcting a documenting error you should..... Ans:
Usually strike a single line, but follow your hospital policy
What are the purposes of client record Ans: Communication, in turn
preventing fragmentation, repetition and delays
Planning
© 2026 Assignment Expert
Baseline and ongoing data
Auditing health agencies review client record for quality assurance
Guru01 - Stuvia
purposes
Research
Treatment plans
What are DRGs? Ans: Diagnostic related guidelines are used to give a
general idea of how long your hospital stay will be
What would a case manager look at when it comes to insurance? Ans:
How many days the client insurance will pay for
The court can pull the client chart for evidence unless Ans: The client
objects because the information is confidential
The source oriented record is Ans: Traditional, narrative charting
,For Expert help and assignment handling,
3
Information about a particular problem is distributed throughout the
record
Each discipline makes notations in a separate section
what is narrative charting Ans: Notes that include routine care, normal
findings, and client problems
Often chronologic
© 2026 Assignment Expert
The problem oriented medical record Ans: Is data arranged according
to client problem
Guru01 - Stuvia
Health team contributes to the problem list, plan of care and progress
notes
Encourages collaboration
Easier to track the status of problems
What is the data base in the problem oriented medical record Ans: All
information known about the client when the client first enters the health
care agency
what is the problem list the problem oriented medical record Ans: The
NANDAs, listed in order in which they are indentured and others resolved
What is the plan of care in the problem oriented medical record Ans:
Made with reference to active problems
, For Expert help and assignment handling,
4
Generated by individual who lists the problems
What are the progress notes in the problem oriented medical record
Ans: Made by all health care professionals involved in a clients care
Uses SOAP, SOAPIE, and SOAPIER
What does SOAP stand for? Ans: Subjective
© 2026 Assignment Expert
Objective
Assessment
Guru01 - Stuvia
Plan
What does PIE stand for? Ans: Problems
Interventions
Evaluations
What doe DAR stand for? Ans: Data (assessment)
Action (plan and implementation)
Response (evaluation)
What is focus charting Ans: Focused on client concerns and strengths
Organized in DAR form
