NR302 Flashcard 1 2026

NR302 Flashcard 1 2026
__ the health assessment is the first step to creating the database of an individual's experience with a
healthcare provider, for it is this data that will inform the decisions made by all members of the
healthcare team. Although the healthcare provider is the leader of the healthcare team, no single health
professional is responsible for the information in the health record. - correct answersDocumenting

When documenting the assessment of the eyes, the nurse forgets the appropriate abbreviation for
normal reaction of the pupils. Which actions are appropriate at this time?

1. Do not chart that portion of the assessment.
2. Write the whole word instead of an abbreviation.
3. Use the first three letters of the word as the abbreviation.
4. Look up the appropriate abbreviation and use it.
5. Just use something close, most medical professionals will know what it is. - correct answers2
4

While documenting a physical assessment, the nurse realizes they did not check the client's eyes. What
should the nurse do?

1. Document normal findings; the client did not tell the nurse anything was wrong with their eyes.
2. Document something, so it does not look like it was forgotten.
3. Complete the proper assessment and then document.
4. Just skip it; there is probably nothing wrong. - correct answers3

SOAP stands for:

1. Subjective, Official, Assessment, Personal
2. Succinct, Objective, Accurate, Plan
3. Succinct, Official, Assessment, Personal
4. Subjective, Objective, Assessment, Plan - correct answers4

Though the goal of health assessment is the collection of data on which to make decisions for care,
without proper _ of findings by all healthcare team members, it is difficult to provide coordinated,
holistic care. Within the healthcare system, this by health professionals serves a larger purpose as well. -
correct answersDOCUMENTATIONS

- Assess
- Plan
- Implement
- Eval

1. Though the documentation of actions taken with and for the client to support their health is not part
of the health assessment, determining the best actions to take is based on data collected during
assessment and updated as the individual responds to care.
2. Focused on monitoring the individual's progress toward their health goals. As the individual's health
improves, plans and interventions transition from treating illness to optimizing health.

, 3. Documents the expected health outcomes and plan of care for the individual. Just as each health
professional collects assessment data that is most relevant to their discipline, focuses on the goals of
care and interventions for which they will support the individual.
4. should be completed with the examination. Document in (EMR) or electronic health record (EHR).
However you document this stage, you must document thoroughly. - correct answers1. Implementation
2. Eval
3. Plan
4. Assessment

Which statements best describe the goals of timely and accurate documentation of health assessment?

1. To provide a comprehensive database of a person's current state of health and wellness
2. To fulfill the expectations of your professional role
3. To establish goals for care collaboratively with the individual seeking care
4. To prevent legal action
5. To provide information to the healthcare team - correct answers1
3
5

All methods of documenting the health assessment present risks and benefits. What is one risk that
charting by exception and narrative documentation have in common?
1. Decreased time in charting
2. Important information may not be charted
3. Easier to find exceptions to normal findings
4. Lengthy entries in which important information may be overlooked - correct answers2

Documentation Best Practices - correct answers- Begin each entry with the date/time.
- Record data factually and objectively. This includes observations of a client's behavior and the actions
of another health professional.
- Use complete descriptions of assessments and care in an objective manner, avoiding generalizations.
- Use the client's words, in quotes, to record what they have said.
- Using the client's words regarding personal preferences (e.g., food preferences and daily routine),
spiritual needs (e.g., visit from a clergy member or time to pray undisturbed), and health concerns (e.g.,
cost of care or no pharmacy in their neighborhood) provides information related to care of the entire
person, not just their alteration in health. This is most important when the client is expressing emotions
or thoughts of harming themselves or someone else.
- Document consultations with providers that seek to clarify a prescribed intervention.
- Document only what you have observed or done yourself.
- Document as care is provided, rather than waiting for the end of the shift. This increases accuracy of
documentation. If a late entry is needed, document the time the charting was completed, then note the
time care was provided at the start of the note.
- Correct all errors when discovered. The process for making a correction in an EHR may vary by
software.
- End each entry with your signature and role (RN; LVN; NA; MD; OT). This step is often completed by the
EHR and is linked to your login credentials. First initial, last name, role. (C. Simpson, RN)
- Document using approved abbreviations and correct medical terminology, spelled correctly.
- Entries should be clear and concise.
- Finally, always protect your computer password.