1|Page
NSRG 91 FINAL LATEST 2025 ACTUAL EXAM WITH COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS (100% VERIFIED
ANSWERS) |ALREADY GRADED A+| ||PROFESSOR VERIFIED||
What was florence nightingale missions? - ANSWER-to improve
hygiene practixes to decrease the death rate in hospitals.
What is the purpose of documentation? - ANSWER-Facilitation of
information flow to support continuity, quality, and safety of care.
What is the goal of documentation? - ANSWER-To describe facts
clearly and concisely to improve communication.
What are the characteristics of good documentation? - ANSWER-
Clear, concise, accurate, complete, objective, timely, and free of
spelling or grammar errors.
What does EMR stand for? - ANSWER-Electronic Medical
Records - a record of one episode of care.
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What does EHR stand for? - ANSWER-Electronic Health Records
- a longitudinal record of health that includes in-patient and out-
patient documentation.
What are the common parts of a healthcare record? - ANSWER-
Patient identification, informed consent for treatments, medical
diagnosis and progress notes, doctors' orders, nursing database,
operative record, discharge plan, and summary.
What terms should not be used in documentation? - ANSWER-
Terms like 'seems', 'appears', 'apparently', 'small', 'large', 'usual
day', 'good night', 'nice man', 'difficult patient' should be avoided.
What must every entry in documentation have? - ANSWER-Date,
time, full signature, and correct titles. Only chart care that you
have provided.
How should other patients be referred to in documentation? -
ANSWER-Instead of using their names, refer to them as 'patient's
room mate'.
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What are the CNO practice standards in regards to
documentation? - ANSWER-Communication, Accountability,
Security
Communication? - ANSWER-Reflects all aspects of the nursing
process, legible, permanent ink, full signature, and designations.
Accountability? - ANSWER-:Never delete, alter, or modify another
nurse's charts.
Security? - ANSWER-Maintain confidentiality, access only info
needed for care, use a secure line to fax or email patient info.
What is POMR? - ANSWER-Problem-Oriented Medical Record.
What does PIE stand for? - ANSWER-Problem, Intervention,
Evaluation.
What does APIE stand for? - ANSWER-Assessment, Problem,
Intervention, Evaluation.
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What does SOAP stand for? - ANSWER-Subjective, Objective,
Assessment, Plan.
What does SOAPIE or SOAPIER stand for? - ANSWER-
Subjective, Objective, Assessment, Plan, Intervention, Evaluation,
(Revision/Recommendation).
What is Focus Charting (DAR)? - ANSWER-Data, Action,
Response.
What is Charting by Exception? - ANSWER-Recording only
abnormal or significant data.
What is a Kardex? - ANSWER-A quick reference with the
patient's summary of basic information.
What are Critical Pathways or Care Maps? - ANSWER-Pre-
printed documents with specific goals, interventions, and time
frames. (e.g., pneumonia patient expected to have a 4 day stay)
NSRG 91 FINAL LATEST 2025 ACTUAL EXAM WITH COMPLETE
QUESTIONS AND CORRECT DETAILED ANSWERS (100% VERIFIED
ANSWERS) |ALREADY GRADED A+| ||PROFESSOR VERIFIED||
What was florence nightingale missions? - ANSWER-to improve
hygiene practixes to decrease the death rate in hospitals.
What is the purpose of documentation? - ANSWER-Facilitation of
information flow to support continuity, quality, and safety of care.
What is the goal of documentation? - ANSWER-To describe facts
clearly and concisely to improve communication.
What are the characteristics of good documentation? - ANSWER-
Clear, concise, accurate, complete, objective, timely, and free of
spelling or grammar errors.
What does EMR stand for? - ANSWER-Electronic Medical
Records - a record of one episode of care.
,2|Page
What does EHR stand for? - ANSWER-Electronic Health Records
- a longitudinal record of health that includes in-patient and out-
patient documentation.
What are the common parts of a healthcare record? - ANSWER-
Patient identification, informed consent for treatments, medical
diagnosis and progress notes, doctors' orders, nursing database,
operative record, discharge plan, and summary.
What terms should not be used in documentation? - ANSWER-
Terms like 'seems', 'appears', 'apparently', 'small', 'large', 'usual
day', 'good night', 'nice man', 'difficult patient' should be avoided.
What must every entry in documentation have? - ANSWER-Date,
time, full signature, and correct titles. Only chart care that you
have provided.
How should other patients be referred to in documentation? -
ANSWER-Instead of using their names, refer to them as 'patient's
room mate'.
,3|Page
What are the CNO practice standards in regards to
documentation? - ANSWER-Communication, Accountability,
Security
Communication? - ANSWER-Reflects all aspects of the nursing
process, legible, permanent ink, full signature, and designations.
Accountability? - ANSWER-:Never delete, alter, or modify another
nurse's charts.
Security? - ANSWER-Maintain confidentiality, access only info
needed for care, use a secure line to fax or email patient info.
What is POMR? - ANSWER-Problem-Oriented Medical Record.
What does PIE stand for? - ANSWER-Problem, Intervention,
Evaluation.
What does APIE stand for? - ANSWER-Assessment, Problem,
Intervention, Evaluation.
, 4|Page
What does SOAP stand for? - ANSWER-Subjective, Objective,
Assessment, Plan.
What does SOAPIE or SOAPIER stand for? - ANSWER-
Subjective, Objective, Assessment, Plan, Intervention, Evaluation,
(Revision/Recommendation).
What is Focus Charting (DAR)? - ANSWER-Data, Action,
Response.
What is Charting by Exception? - ANSWER-Recording only
abnormal or significant data.
What is a Kardex? - ANSWER-A quick reference with the
patient's summary of basic information.
What are Critical Pathways or Care Maps? - ANSWER-Pre-
printed documents with specific goals, interventions, and time
frames. (e.g., pneumonia patient expected to have a 4 day stay)
