FOUNDATIONS OF NURSING CHAPTER
3: DOCUMENTATION EXAM
QUESTIONS AND ANSWERS GRADED A+
2025/2026
The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse
(LPN/LVN) regarding documentation. Which statement by the preceptor is correct? - ANS it is
important to use only approved medical terms and abbreviations when documenting in the
electronic health record (EHR)
The patient asks the LPN/LVN if he can take his chart with him on discharge from the hospital.
Which response by the nurse is most accurate? - ANS "the chart is the property of the
hospital, but if you need copies of your records, we can arrange that for you."
when reviewing information regarding the problem-oriented medical record (POMR), the
LPN/LVN correctly identifies which guideline? - ANS 3. the charting format is SOAPE or
SOAPIER
the LPN/LVN is using SOAPE method to chart. When documenting the S portion, which entry
demonstrates correct documentation? (select all that apply). - ANS 2. Patient reports left hip
pain 8/10
5. Patient reports nausea after eating
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,The student nurse is correct when identifying which concept regarding documentation as being
correct? - ANS 1. chart as soon and as often as necessary
understanding that health care personnel mist respect the confidentiality of patient records,
which action by the nurse is appropriate? - ANS 3. Reading charts only for a professional
reason
following the orientation to the facility's computer system, which statement by the new nurse is
most accurate? - ANS 1. "I can save on charting time once I am comfortable using the
system."
The nurse demonstrates knowledge of correctly completing an incident report with which
action? - ANS 4. Documenting facts regarding the incident
which statement is correct about formats for documentation? (select all that apply). - ANS 3.
Charting by exception documents those conditions, interventions, or outcomes outside the
norm.
5. EHR systems allow for the patient date to be shared for collaborative care
which statement is a recommended guideline for charting? - ANS 4. The patient's name and
identification number should be on all documents.
which statement is a safe principle of computerized charting? - ANS 4. do not leave patient
information displayed on the monitor.
which accreditation agency specifies guidelines for documentation? - ANS 1. The Joint
Commission (TJC).
What is the primary purpose of Title II of the Health Insurance Portability and Accountability Act
(HIPPA)? - ANS 2. Maintain privacy and confidentiality of patient information
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, which statement is correct about the abbreviations? (select all that apply). - ANS 1. The nurse
should be aware of any abbreviations on the "do not use list"
4. When in doubt the nurse should use the complete word and not the abbreviation.
The nurse documents in the patient record "0830 patient appears to be in severe pain and
refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and analgesic
administered as ordered with adequate relief. J. Doe RN." Which statement about the
documentation is most accurate? - ANS 4. The documentation is unacceptable because it is
vague, non descriptive data without supportive data.
the nurse works in a facility that uses narrative charting for nurses notes. Identify which
documentation is an example of narrative charting. (select all that apply). - ANS 1. patient
alert and oriented x3, PERRLA, hand grips strong and equal
3. patient ambulated 60 ft in the hall, unassisted with steady gait. Currently resting in chair with
no complaints.
5. Patient asking for pain medication for incisional pain 7/10. Hydrocodone 10-325, 2 tablets
administered by mouth while patient was eating lunch. Patient resting in bed with side rails up x
2 and call light in reach
in most states patients can gain access to their medical records by which means? - ANS 2.
submitting a written request to the facility to view the record
the charge nurse in a long-term care facility has been asked by the facility administrator to be
sure that the staff documents in a way that will help ensure appropriate reimbursement for
services provided. The charge nurse should instruct the staff to chart using what system as a
guide? - ANS 1. minimum data sets (MDS)
An elderly patient with pneumonia is in an acute care hospital. Medicare will pay for 4 days of
care in the facility. What prospective payment system is responsible for determining this
reimbursement? - ANS 4. Diagnosis- related groups (DRGs)
CBE - ANS Charting by Exception.
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
3: DOCUMENTATION EXAM
QUESTIONS AND ANSWERS GRADED A+
2025/2026
The nursing preceptor is preparing to speak with the new licensed practical/vocational nurse
(LPN/LVN) regarding documentation. Which statement by the preceptor is correct? - ANS it is
important to use only approved medical terms and abbreviations when documenting in the
electronic health record (EHR)
The patient asks the LPN/LVN if he can take his chart with him on discharge from the hospital.
Which response by the nurse is most accurate? - ANS "the chart is the property of the
hospital, but if you need copies of your records, we can arrange that for you."
when reviewing information regarding the problem-oriented medical record (POMR), the
LPN/LVN correctly identifies which guideline? - ANS 3. the charting format is SOAPE or
SOAPIER
the LPN/LVN is using SOAPE method to chart. When documenting the S portion, which entry
demonstrates correct documentation? (select all that apply). - ANS 2. Patient reports left hip
pain 8/10
5. Patient reports nausea after eating
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,The student nurse is correct when identifying which concept regarding documentation as being
correct? - ANS 1. chart as soon and as often as necessary
understanding that health care personnel mist respect the confidentiality of patient records,
which action by the nurse is appropriate? - ANS 3. Reading charts only for a professional
reason
following the orientation to the facility's computer system, which statement by the new nurse is
most accurate? - ANS 1. "I can save on charting time once I am comfortable using the
system."
The nurse demonstrates knowledge of correctly completing an incident report with which
action? - ANS 4. Documenting facts regarding the incident
which statement is correct about formats for documentation? (select all that apply). - ANS 3.
Charting by exception documents those conditions, interventions, or outcomes outside the
norm.
5. EHR systems allow for the patient date to be shared for collaborative care
which statement is a recommended guideline for charting? - ANS 4. The patient's name and
identification number should be on all documents.
which statement is a safe principle of computerized charting? - ANS 4. do not leave patient
information displayed on the monitor.
which accreditation agency specifies guidelines for documentation? - ANS 1. The Joint
Commission (TJC).
What is the primary purpose of Title II of the Health Insurance Portability and Accountability Act
(HIPPA)? - ANS 2. Maintain privacy and confidentiality of patient information
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, which statement is correct about the abbreviations? (select all that apply). - ANS 1. The nurse
should be aware of any abbreviations on the "do not use list"
4. When in doubt the nurse should use the complete word and not the abbreviation.
The nurse documents in the patient record "0830 patient appears to be in severe pain and
refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and analgesic
administered as ordered with adequate relief. J. Doe RN." Which statement about the
documentation is most accurate? - ANS 4. The documentation is unacceptable because it is
vague, non descriptive data without supportive data.
the nurse works in a facility that uses narrative charting for nurses notes. Identify which
documentation is an example of narrative charting. (select all that apply). - ANS 1. patient
alert and oriented x3, PERRLA, hand grips strong and equal
3. patient ambulated 60 ft in the hall, unassisted with steady gait. Currently resting in chair with
no complaints.
5. Patient asking for pain medication for incisional pain 7/10. Hydrocodone 10-325, 2 tablets
administered by mouth while patient was eating lunch. Patient resting in bed with side rails up x
2 and call light in reach
in most states patients can gain access to their medical records by which means? - ANS 2.
submitting a written request to the facility to view the record
the charge nurse in a long-term care facility has been asked by the facility administrator to be
sure that the staff documents in a way that will help ensure appropriate reimbursement for
services provided. The charge nurse should instruct the staff to chart using what system as a
guide? - ANS 1. minimum data sets (MDS)
An elderly patient with pneumonia is in an acute care hospital. Medicare will pay for 4 days of
care in the facility. What prospective payment system is responsible for determining this
reimbursement? - ANS 4. Diagnosis- related groups (DRGs)
CBE - ANS Charting by Exception.
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
