1 | Page
NSC 114 Exam 2 Questions and Correct
Answers
Giving report or a consult is discussion between Ans: Healthcare
workers
Report can be Ans: Oral, written or computer based
The client record is.... Ans: Also called a chart
Formal legal document that provides evidence of client care
Written or computer based
The process of making an entry on a chart is called Ans:
Recording, charting or documenting
What day were HIPPA regulations updated Ans: April 14, 2003
What are some ways to ensure confidentiality of computer record?
Ans: Never sharing your password
Never leave the computer unintended
Dont display client information where it can be seen
Shred unneeded papers
Follow procedure for documenting sensitive information
IT must install firewall to protect from unauthorized access
© 2025 All rights reserved
, 2 | Page
when it comes to correcting a documenting error you should.....
Ans: Usually strike a single line, but follow your hospital policy
What are the purposes of client record Ans: Communication, in
turn preventing fragmentation, repetition and delays
Planning
Baseline and ongoing data
Auditing health agencies review client record for quality assurance
purposes
Research
Treatment plans
What are DRGs? Ans: Diagnostic related guidelines are used to
give a general idea of how long your hospital stay will be
What would a case manager look at when it comes to insurance?
Ans: How many days the client insurance will pay for
The court can pull the client chart for evidence unless Ans: The
client objects because the information is confidential
The source oriented record is Ans: Traditional, narrative charting
Information about a particular problem is distributed throughout
the record
Each discipline makes notations in a separate section
© 2025 All rights reserved
, 3 | Page
what is narrative charting Ans: Notes that include routine care,
normal findings, and client problems
Often chronologic
The problem oriented medical record Ans: Is data arranged
according to client problem
Health team contributes to the problem list, plan of care and
progress notes
Encourages collaboration
Easier to track the status of problems
What is the data base in the problem oriented medical record Ans:
All information known about the client when the client first enters
the health care agency
what is the problem list the problem oriented medical record Ans:
The NANDAs, listed in order in which they are indentured and
others resolved
What is the plan of care in the problem oriented medical record
Ans: Made with reference to active problems
Generated by individual who lists the problems
What are the progress notes in the problem oriented medical
record Ans: Made by all health care professionals involved in a
clients care
Uses SOAP, SOAPIE, and SOAPIER
© 2025 All rights reserved
, 4 | Page
What does SOAP stand for? Ans: Subjective
Objective
Assessment
Plan
What does PIE stand for? Ans: Problems
Interventions
Evaluations
What doe DAR stand for? Ans: Data (assessment)
Action (plan and implementation)
Response (evaluation)
What is focus charting Ans: Focused on client concerns and
strengths
Organized in DAR form
Holistic perspective of client needs
Nursing process framework for client progress notes
what does charting by exception incorporate? Ans: Flow sheets,
standards of nursing care, bedside chart forms
______ develop standards of nursing practice Ans: Agencies
© 2025 All rights reserved
NSC 114 Exam 2 Questions and Correct
Answers
Giving report or a consult is discussion between Ans: Healthcare
workers
Report can be Ans: Oral, written or computer based
The client record is.... Ans: Also called a chart
Formal legal document that provides evidence of client care
Written or computer based
The process of making an entry on a chart is called Ans:
Recording, charting or documenting
What day were HIPPA regulations updated Ans: April 14, 2003
What are some ways to ensure confidentiality of computer record?
Ans: Never sharing your password
Never leave the computer unintended
Dont display client information where it can be seen
Shred unneeded papers
Follow procedure for documenting sensitive information
IT must install firewall to protect from unauthorized access
© 2025 All rights reserved
, 2 | Page
when it comes to correcting a documenting error you should.....
Ans: Usually strike a single line, but follow your hospital policy
What are the purposes of client record Ans: Communication, in
turn preventing fragmentation, repetition and delays
Planning
Baseline and ongoing data
Auditing health agencies review client record for quality assurance
purposes
Research
Treatment plans
What are DRGs? Ans: Diagnostic related guidelines are used to
give a general idea of how long your hospital stay will be
What would a case manager look at when it comes to insurance?
Ans: How many days the client insurance will pay for
The court can pull the client chart for evidence unless Ans: The
client objects because the information is confidential
The source oriented record is Ans: Traditional, narrative charting
Information about a particular problem is distributed throughout
the record
Each discipline makes notations in a separate section
© 2025 All rights reserved
, 3 | Page
what is narrative charting Ans: Notes that include routine care,
normal findings, and client problems
Often chronologic
The problem oriented medical record Ans: Is data arranged
according to client problem
Health team contributes to the problem list, plan of care and
progress notes
Encourages collaboration
Easier to track the status of problems
What is the data base in the problem oriented medical record Ans:
All information known about the client when the client first enters
the health care agency
what is the problem list the problem oriented medical record Ans:
The NANDAs, listed in order in which they are indentured and
others resolved
What is the plan of care in the problem oriented medical record
Ans: Made with reference to active problems
Generated by individual who lists the problems
What are the progress notes in the problem oriented medical
record Ans: Made by all health care professionals involved in a
clients care
Uses SOAP, SOAPIE, and SOAPIER
© 2025 All rights reserved
, 4 | Page
What does SOAP stand for? Ans: Subjective
Objective
Assessment
Plan
What does PIE stand for? Ans: Problems
Interventions
Evaluations
What doe DAR stand for? Ans: Data (assessment)
Action (plan and implementation)
Response (evaluation)
What is focus charting Ans: Focused on client concerns and
strengths
Organized in DAR form
Holistic perspective of client needs
Nursing process framework for client progress notes
what does charting by exception incorporate? Ans: Flow sheets,
standards of nursing care, bedside chart forms
______ develop standards of nursing practice Ans: Agencies
© 2025 All rights reserved
