NURS 258 - Documentation (E1) Exam Questions and Answers Fully Solved Latest Version 2025 Graded
A+
documentation (def.) - Answers anything written or printed; record of proof of patient actions or
activities
Documentation must.... - Answers - be accurate, comprehensive and easily retrievable
- show continuity of care
- track patient outcomes
- reflect current standards of nursing practice
Purpose of documentation: - Answers -Provides a legal, serial record of client's condition, evaluation and
re-evaluation results, course of therapeutic intervention and response to intervention from referral to
discharge
-Serves as an information source for client care, can be used by a covering therapist in absence of
primary therapist
-Enhances communication among healthcare or educational team members
-Provides data for use in intervention, program evaluation, research, education and reimbursement
Guidelines for Documentation include information that is: - Answers (1) Factual
(2) Accurate
(3) Complete
(4) Current
(5) Organized
Factual documentation is - Answers descriptive and objective
is free of judgement and personal opinions
creates a clear picture
documents what you see, hear, smell and feel
Documentation is accurate by: - Answers providing exact measures
being brief & concise (only documenting activity that is specific)
using appropriate terminology with approved abbreviations
A+
documentation (def.) - Answers anything written or printed; record of proof of patient actions or
activities
Documentation must.... - Answers - be accurate, comprehensive and easily retrievable
- show continuity of care
- track patient outcomes
- reflect current standards of nursing practice
Purpose of documentation: - Answers -Provides a legal, serial record of client's condition, evaluation and
re-evaluation results, course of therapeutic intervention and response to intervention from referral to
discharge
-Serves as an information source for client care, can be used by a covering therapist in absence of
primary therapist
-Enhances communication among healthcare or educational team members
-Provides data for use in intervention, program evaluation, research, education and reimbursement
Guidelines for Documentation include information that is: - Answers (1) Factual
(2) Accurate
(3) Complete
(4) Current
(5) Organized
Factual documentation is - Answers descriptive and objective
is free of judgement and personal opinions
creates a clear picture
documents what you see, hear, smell and feel
Documentation is accurate by: - Answers providing exact measures
being brief & concise (only documenting activity that is specific)
using appropriate terminology with approved abbreviations
