LECTURE 4 CNUR 103 Practice Test
Questions with Solved Solutions 2025-
2026 Edition.
Chart - Answer A document compiled to provide a complete record of patient care
Documentation - Answer Written information about a client that describes the care or
service provided to that client - done when you do any patient care
What is the biggest function of documentation? - Answer Communication - it is a tool to
relay the message to all members in the healthcare system
Purposes of documentation - Answer Promotes equality and improvement and manages risk
Professional accountability
Liability protection (law)
Funding and resource management eg being short staffed
Education
HIPA - Answer Provincial - health information protective act
Who should document - Answer Whoever is responsible for the nurses care should chart but
others can chart in as well
Third part documentation? - Answer Not a good idea unless:
-designed recorder
-auxiliary or external personnel
-client or family
-students
-co-signing and counter signing entries
When applicable always get the patients point of view eg "patient states: 'pain 9/10' "
, And the second RN will review the charting and add information as needed
What is the "master signature form" - Answer -Provides a record of all caregivers involved in
the client's care
-Information filled out on the first contact with the client and only entered once during each
admission.
-Contains name (printed and signature), initials, designation and date of initial contact
-Must be available on each individual client's chart
Discharge documentation includes (5) - Answer -Patient status at discharge
-Instructions provided to the patient (both written and verbal)
-Preparing patient for any transitions (what to expect in the course of recovery)
-Arrangements for follow-up (appointments made or need to be made)
-Ensuring that the patient understands teaching and, if appropriate, family's involvement
(4) key elements of charting - Answer Flow sheets
Clinical standards -
Standardized care plans
Progress notes
Confidentiality in terms of health care? - Answer "ensure that information is accessible only
to those who are authorized to have access"
What do you do with late entries - Answer -Add the entry on the first available line
-Label the entry "Late Entry" to indicate that it is out of sequence
-Record the time and date of entry
-In the body of the entry, record the time and date it should have been made
What do you do if you make a writing mistake while documenting (3) - Answer cross it out
(DONT ERASE)
write "VOID"
initial
Questions with Solved Solutions 2025-
2026 Edition.
Chart - Answer A document compiled to provide a complete record of patient care
Documentation - Answer Written information about a client that describes the care or
service provided to that client - done when you do any patient care
What is the biggest function of documentation? - Answer Communication - it is a tool to
relay the message to all members in the healthcare system
Purposes of documentation - Answer Promotes equality and improvement and manages risk
Professional accountability
Liability protection (law)
Funding and resource management eg being short staffed
Education
HIPA - Answer Provincial - health information protective act
Who should document - Answer Whoever is responsible for the nurses care should chart but
others can chart in as well
Third part documentation? - Answer Not a good idea unless:
-designed recorder
-auxiliary or external personnel
-client or family
-students
-co-signing and counter signing entries
When applicable always get the patients point of view eg "patient states: 'pain 9/10' "
, And the second RN will review the charting and add information as needed
What is the "master signature form" - Answer -Provides a record of all caregivers involved in
the client's care
-Information filled out on the first contact with the client and only entered once during each
admission.
-Contains name (printed and signature), initials, designation and date of initial contact
-Must be available on each individual client's chart
Discharge documentation includes (5) - Answer -Patient status at discharge
-Instructions provided to the patient (both written and verbal)
-Preparing patient for any transitions (what to expect in the course of recovery)
-Arrangements for follow-up (appointments made or need to be made)
-Ensuring that the patient understands teaching and, if appropriate, family's involvement
(4) key elements of charting - Answer Flow sheets
Clinical standards -
Standardized care plans
Progress notes
Confidentiality in terms of health care? - Answer "ensure that information is accessible only
to those who are authorized to have access"
What do you do with late entries - Answer -Add the entry on the first available line
-Label the entry "Late Entry" to indicate that it is out of sequence
-Record the time and date of entry
-In the body of the entry, record the time and date it should have been made
What do you do if you make a writing mistake while documenting (3) - Answer cross it out
(DONT ERASE)
write "VOID"
initial
