NUR 134 Documentation Exam Questions
and Answers 2025/2026 A+ Graded 100%
Verified
documentation - ANS-the written or electronic legal record of all pertinent interactions with the
patient-assessing, diagnosing, planning, implementing, and evaluating
patient record - ANS-compilation of a patient's health information that permanently documents
all care given and reflects the quality of care provided
reimbursement/financial, legal, research - ANS-the patient record may be used for
_______/_______ purposes, as a ________ document, or for _________ & education
the chart - ANS-The patient record is known as "____ _____"
Electronic medical record (EMR) - ANS-An electronic "patient record"; utilized by agencies with
the same ownership
Electronic health record (EHR) - ANS-Similar to EMR; more comprehensive, information is
shared among more healthcare providers
Health information exchange (HIE) - ANS-organization that provides services to enable the
electronic sharing of health information
content, timing, format, accountability, confidentiality - ANS-What are the 5 documentation
guidelines?
content - ANS-guideline; complete, accurate, concise, current, organized, and descriptive
timing - ANS-guideline; timely manner, chronologically
False - ANS-(T/F) It is acceptable to "pre chart"
Military - ANS-Always use ________ time when documenting
format - ANS-guideline; correct chart, utilized correct forms, standard terminology, and
appropriate abbreviations
, accountability - ANS-guideline; signature/title to each entry
confidentiality - ANS-guideline; HIPAA--maintain privacy/protect information
patient care summary - ANS-overview of valuable patient information; "snapshot" of patient;
includes baseline information, demographics, and diagnosis
progress notes/nurse notes - ANS-informs caregivers of progress toward outcomes; utilized by
physicians and nurses; descriptive/accurate/concise
progress notes/nurse notes - ANS-SOAP, PIE, APIE, and Narrative notes are all examples of
what?
flow sheets - ANS-tools used to efficiently chart routine care provided, assessment data, and
patient activities/rounding; easy to navigate
graphic records - ANS-form used to record specific variables such as v/s, I&O, and ht/wt; easy
to track "trends" over a designated time frame
24hr Patient care/Acuity Charting Form - ANS-consolidation of nursing record; determines
hours of care based on type & number of interventions required for each pt--determines acuity
of patients; useful for staffing patterns and nurse-patient ratio can be considered
acuity - ANS-_______ of patients refers to how sick they are on a 1-5 scale with 1 needing the
most care and 5 needing the least care
Source-Oriented Medical Record (SOMR) - ANS-paper format in which each health care group
keeps data on its own separate form; includes admission sheet, orders, flow sheet, med sheet,
graphic sheet, physician progress notes, nurse narrative note, misc.
narrative note - ANS-progress notes written by nurses in a source-oriented record that include
a description of the status of the problem, related nursing interventions, patient responses, and
needed revisions to the plan of care
problem-oriented medical record (POMR) - ANS-documentation system organized according to
the person's specific health problems rather than source of information; emphasis on patient's
problem; includes database, problem list, plan of care, and progress notes
SOAP, APIE, PIE - ANS-Nurse's note documentation in a POMR can be done in which 3
formats?
Subjective, objective, assessment, plan - ANS-SOAP
and Answers 2025/2026 A+ Graded 100%
Verified
documentation - ANS-the written or electronic legal record of all pertinent interactions with the
patient-assessing, diagnosing, planning, implementing, and evaluating
patient record - ANS-compilation of a patient's health information that permanently documents
all care given and reflects the quality of care provided
reimbursement/financial, legal, research - ANS-the patient record may be used for
_______/_______ purposes, as a ________ document, or for _________ & education
the chart - ANS-The patient record is known as "____ _____"
Electronic medical record (EMR) - ANS-An electronic "patient record"; utilized by agencies with
the same ownership
Electronic health record (EHR) - ANS-Similar to EMR; more comprehensive, information is
shared among more healthcare providers
Health information exchange (HIE) - ANS-organization that provides services to enable the
electronic sharing of health information
content, timing, format, accountability, confidentiality - ANS-What are the 5 documentation
guidelines?
content - ANS-guideline; complete, accurate, concise, current, organized, and descriptive
timing - ANS-guideline; timely manner, chronologically
False - ANS-(T/F) It is acceptable to "pre chart"
Military - ANS-Always use ________ time when documenting
format - ANS-guideline; correct chart, utilized correct forms, standard terminology, and
appropriate abbreviations
, accountability - ANS-guideline; signature/title to each entry
confidentiality - ANS-guideline; HIPAA--maintain privacy/protect information
patient care summary - ANS-overview of valuable patient information; "snapshot" of patient;
includes baseline information, demographics, and diagnosis
progress notes/nurse notes - ANS-informs caregivers of progress toward outcomes; utilized by
physicians and nurses; descriptive/accurate/concise
progress notes/nurse notes - ANS-SOAP, PIE, APIE, and Narrative notes are all examples of
what?
flow sheets - ANS-tools used to efficiently chart routine care provided, assessment data, and
patient activities/rounding; easy to navigate
graphic records - ANS-form used to record specific variables such as v/s, I&O, and ht/wt; easy
to track "trends" over a designated time frame
24hr Patient care/Acuity Charting Form - ANS-consolidation of nursing record; determines
hours of care based on type & number of interventions required for each pt--determines acuity
of patients; useful for staffing patterns and nurse-patient ratio can be considered
acuity - ANS-_______ of patients refers to how sick they are on a 1-5 scale with 1 needing the
most care and 5 needing the least care
Source-Oriented Medical Record (SOMR) - ANS-paper format in which each health care group
keeps data on its own separate form; includes admission sheet, orders, flow sheet, med sheet,
graphic sheet, physician progress notes, nurse narrative note, misc.
narrative note - ANS-progress notes written by nurses in a source-oriented record that include
a description of the status of the problem, related nursing interventions, patient responses, and
needed revisions to the plan of care
problem-oriented medical record (POMR) - ANS-documentation system organized according to
the person's specific health problems rather than source of information; emphasis on patient's
problem; includes database, problem list, plan of care, and progress notes
SOAP, APIE, PIE - ANS-Nurse's note documentation in a POMR can be done in which 3
formats?
Subjective, objective, assessment, plan - ANS-SOAP
