1
NSC 114 Exam 2 Questions with Answers (100% Correct
Answers)
Giving report or a consult is discussion between Answer: Healthcare
workers
Report can be Answer: Oral, written or computer based
The client record is.... Answer: 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 Answer: Recording,
charting or documenting
What day were HIPPA regulations updated Answer: April 14, 2003
What are some ways to ensure confidentiality of computer record?
Answer: Never sharing your password
Never leave the computer unintended
Dont display client information where it can be seen
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,2
Shred unneeded papers
Follow procedure for documenting sensitive information
IT must install firewall to protect from unauthorized access
when it comes to correcting a documenting error you should.....
Answer: Usually strike a single line, but follow your hospital policy
What are the purposes of client record Answer: 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? Answer: Diagnostic related guidelines are used to
give a general idea of how long your hospital stay will be
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,3
What would a case manager look at when it comes to insurance?
Answer: How many days the client insurance will pay for
The court can pull the client chart for evidence unless Answer: The
client objects because the information is confidential
The source oriented record is Answer: Traditional, narrative charting
Information about a particular problem is distributed throughout the
record
Each discipline makes notations in a separate section
what is narrative charting Answer: Notes that include routine care,
normal findings, and client problems
Often chronologic
The problem oriented medical record Answer: Is data arranged
according to client problem
Health team contributes to the problem list, plan of care and progress
notes
Encourages collaboration
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, 4
Easier to track the status of problems
What is the data base in the problem oriented medical record Answer:
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 Answer:
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
Answer: Made with reference to active problems
Generated by individual who lists the problems
What are the progress notes in the problem oriented medical record
Answer: Made by all health care professionals involved in a clients
care
Uses SOAP, SOAPIE, and SOAPIER
What does SOAP stand for? Answer: Subjective
Objective
Assessment
© 2025 All rights reserved
NSC 114 Exam 2 Questions with Answers (100% Correct
Answers)
Giving report or a consult is discussion between Answer: Healthcare
workers
Report can be Answer: Oral, written or computer based
The client record is.... Answer: 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 Answer: Recording,
charting or documenting
What day were HIPPA regulations updated Answer: April 14, 2003
What are some ways to ensure confidentiality of computer record?
Answer: Never sharing your password
Never leave the computer unintended
Dont display client information where it can be seen
© 2025 All rights reserved
,2
Shred unneeded papers
Follow procedure for documenting sensitive information
IT must install firewall to protect from unauthorized access
when it comes to correcting a documenting error you should.....
Answer: Usually strike a single line, but follow your hospital policy
What are the purposes of client record Answer: 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? Answer: Diagnostic related guidelines are used to
give a general idea of how long your hospital stay will be
© 2025 All rights reserved
,3
What would a case manager look at when it comes to insurance?
Answer: How many days the client insurance will pay for
The court can pull the client chart for evidence unless Answer: The
client objects because the information is confidential
The source oriented record is Answer: Traditional, narrative charting
Information about a particular problem is distributed throughout the
record
Each discipline makes notations in a separate section
what is narrative charting Answer: Notes that include routine care,
normal findings, and client problems
Often chronologic
The problem oriented medical record Answer: Is data arranged
according to client problem
Health team contributes to the problem list, plan of care and progress
notes
Encourages collaboration
© 2025 All rights reserved
, 4
Easier to track the status of problems
What is the data base in the problem oriented medical record Answer:
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 Answer:
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
Answer: Made with reference to active problems
Generated by individual who lists the problems
What are the progress notes in the problem oriented medical record
Answer: Made by all health care professionals involved in a clients
care
Uses SOAP, SOAPIE, and SOAPIER
What does SOAP stand for? Answer: Subjective
Objective
Assessment
© 2025 All rights reserved
