CHAPTER 26 INFORMATICS AND DOCUMENTATION
QUESTIONS WITH 100% RATED ANSWERS 2025/2026
LATEST UPDATE/GET A+
What type of report is given at the end of a shift so that the next nurse can follow the appropriate
treatment plan and care for the patient?
a. discharge summary
b. incident report
c. handoff report
d. telephone report - C
Which section of the health record includes information needed to contact the guardian of a
patient?
a. discharge summary
b. nurse's administration assessment
c. nurse's notes
d. patient care summary - D
Which response by the nurse is accurate for a patient requesting a copy of the patient's medical
record?
a. tell the patient that only family may read the record
b. indicate that the patient has the right to read the record
c. state that the patient is not allowed to read the record
d. explain that only health care workers have access to the record - B
Which method would the nurse use to dispose of printed patient information?
a. rip several times and place in a standard trash can
b. place in the patient's paper-based chart
c. place in a secure canister marked for shredding
d. burn the documents - C
Which system in the electronic health record (EHR) provides warnings to alert a health care
provider of patient allergies when prescribing medications?
a. Administrative information system
b. Computerized provider order entry (CPOE)
c. clinical decision support system (CDSS)
d. Clinical information system (CIS) - C
Which organization addresses the quality of health care documentation? SATA
a. American Nurses Association (ANA)
b. The Joint Commission
c. Diagnosis-related groups (DRGs)
d. National Committee for Quality Assurance (NCQA)
e. Health Insurance Portability and Accountability Act of 1996 (HIPAA) - B, D
In which section of the patient health record would the nurse enter subjective and objective data?
, a. Care plan
b. patient care summary
c. problem list
d. progress notes - D
Which characteristic is an advantage of effective documentation? SATA
a. repetition of therapy
b. saving time
c. minimizing error
d. effective continuity of patient acre
e. omission of treatment - B, C, D
Which system enables the ability to review patient education information provided to the patient
during previous appointments?
a. information technology
b. electronic health record
c. personal health information
d. administrative information system - B
Which action reflects how medical insurance companies use documentation of a patients health
information?
a. provide preventative care to the patient
b. determine payment or reimbursement for health care services
c. reduce the cost of the monthly premium paid by the patient
d. decrease the cost of health care services provided to the patient - B
Which location in the patient's health record is used to document urine output?
a. admission sheet
b. operative report
c. health care provider's prescription sheet
d. flow sheet - D
Which section of health record maintains demographic information?
a. nurse's notes
b. patient care summary
c. graphic sheet and flow sheet
d. nurse's administration assessment - B
Which type of documentation is based on the concept that all standards for normal assessment
findings or for routine care activities are met unless otherwise documented?
a. charting by exception
b. DAR (data, action or nursing intervention, and response of the patient report)
c. PIE (problem, intervention, evaluation) report
d. narrative report - A
Which action would the nurse take when documenting patient care? SATA
QUESTIONS WITH 100% RATED ANSWERS 2025/2026
LATEST UPDATE/GET A+
What type of report is given at the end of a shift so that the next nurse can follow the appropriate
treatment plan and care for the patient?
a. discharge summary
b. incident report
c. handoff report
d. telephone report - C
Which section of the health record includes information needed to contact the guardian of a
patient?
a. discharge summary
b. nurse's administration assessment
c. nurse's notes
d. patient care summary - D
Which response by the nurse is accurate for a patient requesting a copy of the patient's medical
record?
a. tell the patient that only family may read the record
b. indicate that the patient has the right to read the record
c. state that the patient is not allowed to read the record
d. explain that only health care workers have access to the record - B
Which method would the nurse use to dispose of printed patient information?
a. rip several times and place in a standard trash can
b. place in the patient's paper-based chart
c. place in a secure canister marked for shredding
d. burn the documents - C
Which system in the electronic health record (EHR) provides warnings to alert a health care
provider of patient allergies when prescribing medications?
a. Administrative information system
b. Computerized provider order entry (CPOE)
c. clinical decision support system (CDSS)
d. Clinical information system (CIS) - C
Which organization addresses the quality of health care documentation? SATA
a. American Nurses Association (ANA)
b. The Joint Commission
c. Diagnosis-related groups (DRGs)
d. National Committee for Quality Assurance (NCQA)
e. Health Insurance Portability and Accountability Act of 1996 (HIPAA) - B, D
In which section of the patient health record would the nurse enter subjective and objective data?
, a. Care plan
b. patient care summary
c. problem list
d. progress notes - D
Which characteristic is an advantage of effective documentation? SATA
a. repetition of therapy
b. saving time
c. minimizing error
d. effective continuity of patient acre
e. omission of treatment - B, C, D
Which system enables the ability to review patient education information provided to the patient
during previous appointments?
a. information technology
b. electronic health record
c. personal health information
d. administrative information system - B
Which action reflects how medical insurance companies use documentation of a patients health
information?
a. provide preventative care to the patient
b. determine payment or reimbursement for health care services
c. reduce the cost of the monthly premium paid by the patient
d. decrease the cost of health care services provided to the patient - B
Which location in the patient's health record is used to document urine output?
a. admission sheet
b. operative report
c. health care provider's prescription sheet
d. flow sheet - D
Which section of health record maintains demographic information?
a. nurse's notes
b. patient care summary
c. graphic sheet and flow sheet
d. nurse's administration assessment - B
Which type of documentation is based on the concept that all standards for normal assessment
findings or for routine care activities are met unless otherwise documented?
a. charting by exception
b. DAR (data, action or nursing intervention, and response of the patient report)
c. PIE (problem, intervention, evaluation) report
d. narrative report - A
Which action would the nurse take when documenting patient care? SATA
