NSE 101 DOCUMENTATION EXAM
QUESTIONS WITH COMPLETE
SOLUTIONS
What should I consider in terms of ensuring my hand-written documentation is LEGIBLE
and completed in PERMANENT INK?
Can I use ABBREVIATIONS and SYMBOLS?
Accountability - Answer- Nurses are accountable for ensuring their documentation of
client care is accurate, timely, and complete
Common questions to ensure accountability - Answer- How do I record the DATE and
TIME of my documentation?
How do I ensure that my documentation is TIMELY and when do I indicate it as a LATE
ENTRY?
What does it mean to document in a CHRONOLOGICAL ORDER?
How do I adhere to the indicator of not leaving EMPTY LINES?
What do I do if I make ERRORS while documenting?
Security - Answer- Nurses safeguard client health information by maintaining
confidentiality and acting in accordance with information retention and destruction
policies and procedures that are consistent with the standard(s) and legislation.
Common questions to ensure security - Answer- Who has the right to ACCESS the
client's health record?
How do I maintain CONFIDENTIALITY of client health information?
What are the two federal privacy laws enforced by the Office of the Privacy
Commissioner of Canada? - Answer- 1. Privacy Act
2. Personal Information Protection and Electronic Documents Act (PIPEDA)
, Privacy Act - Answer- Relates to how the government protects the privacy of a person's
information and a person's right to access and correct personal information that the
government collects, uses, or discloses
Personal Information Protection and Electronic Documents Act (PIPEDA) - Answer-
Applies to private-sector-organizations that collect, use, and disclose personal
information.
Personal Health Information Act (PHIPA) - Answer- - Legislates the collection, use, and
disclosure of personal health info by health info custodians.
- Applies to both health info custodians, like HCPs, and to persons who may receive
personal health info from custodians
- Requires that custodians take reasonable steps to ensure that PHI is accurate,
current, and complete and protected from loss, theft, or unauthorized use or disclosure
- Consent is required for the collection, use, and disclosure of PHI
Disclosure exceptions - Answer- - Other individuals working in the healthcare system
- Public health authorities
- Family
- Proceedings
- Research
- Planning and management of a health system
- Health data institute
What are the three main documentation methods? - Answer- 1. Charging by exception
2. Narrative
3. Nursing process
What is another method sometimes used? - Answer- SBAR (Situation, Background,
Assessment, Recommendation)
Charging by exception - Answer- - Not commonly used, but some specific units find
helpful
- Charting when a finding is not normal (out of the norms of ranges provided)
Narrative - Answer- - Chronological
- Storied format and sequential order
- What happened?
- When did it happen?
- Who was involved?
- How the client responded, etc
What is documentation? - Answer- Paper or electronic record keeping about a client's
state of health and their care. Typically referred to as the "client's chart" or the "client's
health record."
QUESTIONS WITH COMPLETE
SOLUTIONS
What should I consider in terms of ensuring my hand-written documentation is LEGIBLE
and completed in PERMANENT INK?
Can I use ABBREVIATIONS and SYMBOLS?
Accountability - Answer- Nurses are accountable for ensuring their documentation of
client care is accurate, timely, and complete
Common questions to ensure accountability - Answer- How do I record the DATE and
TIME of my documentation?
How do I ensure that my documentation is TIMELY and when do I indicate it as a LATE
ENTRY?
What does it mean to document in a CHRONOLOGICAL ORDER?
How do I adhere to the indicator of not leaving EMPTY LINES?
What do I do if I make ERRORS while documenting?
Security - Answer- Nurses safeguard client health information by maintaining
confidentiality and acting in accordance with information retention and destruction
policies and procedures that are consistent with the standard(s) and legislation.
Common questions to ensure security - Answer- Who has the right to ACCESS the
client's health record?
How do I maintain CONFIDENTIALITY of client health information?
What are the two federal privacy laws enforced by the Office of the Privacy
Commissioner of Canada? - Answer- 1. Privacy Act
2. Personal Information Protection and Electronic Documents Act (PIPEDA)
, Privacy Act - Answer- Relates to how the government protects the privacy of a person's
information and a person's right to access and correct personal information that the
government collects, uses, or discloses
Personal Information Protection and Electronic Documents Act (PIPEDA) - Answer-
Applies to private-sector-organizations that collect, use, and disclose personal
information.
Personal Health Information Act (PHIPA) - Answer- - Legislates the collection, use, and
disclosure of personal health info by health info custodians.
- Applies to both health info custodians, like HCPs, and to persons who may receive
personal health info from custodians
- Requires that custodians take reasonable steps to ensure that PHI is accurate,
current, and complete and protected from loss, theft, or unauthorized use or disclosure
- Consent is required for the collection, use, and disclosure of PHI
Disclosure exceptions - Answer- - Other individuals working in the healthcare system
- Public health authorities
- Family
- Proceedings
- Research
- Planning and management of a health system
- Health data institute
What are the three main documentation methods? - Answer- 1. Charging by exception
2. Narrative
3. Nursing process
What is another method sometimes used? - Answer- SBAR (Situation, Background,
Assessment, Recommendation)
Charging by exception - Answer- - Not commonly used, but some specific units find
helpful
- Charting when a finding is not normal (out of the norms of ranges provided)
Narrative - Answer- - Chronological
- Storied format and sequential order
- What happened?
- When did it happen?
- Who was involved?
- How the client responded, etc
What is documentation? - Answer- Paper or electronic record keeping about a client's
state of health and their care. Typically referred to as the "client's chart" or the "client's
health record."
