FUNDAMENTALS OF NURSING:
DOCUMENTATION EXAM QUESTIONS
AND ANSWERS GRADED A+ 2025/2026
Documentation: - ANS Produces a written account of pertinent patient data, nursing clinical
decision and interventions, and patient responses in a health care record.
Communication - ANS Means by which patient needs and progress, individual therapies,
patient education, and discharge planning are conveyed to others in the health care team.
Legal document - ANS Describes exactly what happens to the patient and must follow agency
standards.
Diagnostic-related groups (DRGs) - ANS Classification system based on patients' medical
diagnoses that support reimbursement.
Education - ANS Learning the nature of an illness and the individual patient's responses.
Research - ANS Gathering of statistical data of clinical disorders, complications, therapies,
recovery, and deaths.
Auditing - ANS Objective, ongoing reviews to determine the degree to which quality
improvement standards are met.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, The purpose of the electronic health record is: - ANS a. A positive impact on the quality of
patient care through interdisciplinary collaboration with improved data availability.
b. Improve patient safety through the use of clinical decision support.
According to HIPAA (Health Insurance Portability and Accountability Act), to eliminate barriers
that could delay care, providers are: - ANS a. Providers are required to notify patients of their
privacy policy and make a reasonable effort to get written acknowledgement of this notification.
b. HIPAA requires that disclosure or requests regarding health information are limited to the
minimum necessary.
The standards of documentation by the Joint Commission require: - ANS The standards of
documentation by The Joint Commission require documentation within the context of the
nursing process, as well as evidence of patient and family teaching and discharge planning.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Factual - ANS A factual record contains descriptive, objective information about what
a nurse sees, hears, feels, and smells.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Accurate - ANS An accurate record uses exact measurements, contains concise data,
contains only approved abbreviations, uses correct spelling, and identifies the date and
caregiver.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Complete - ANS A complete record contains all appropriate and essential
information.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Current - ANS Current records contain timely entries with immediate documentation
of information as it is collected from the patient.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
DOCUMENTATION EXAM QUESTIONS
AND ANSWERS GRADED A+ 2025/2026
Documentation: - ANS Produces a written account of pertinent patient data, nursing clinical
decision and interventions, and patient responses in a health care record.
Communication - ANS Means by which patient needs and progress, individual therapies,
patient education, and discharge planning are conveyed to others in the health care team.
Legal document - ANS Describes exactly what happens to the patient and must follow agency
standards.
Diagnostic-related groups (DRGs) - ANS Classification system based on patients' medical
diagnoses that support reimbursement.
Education - ANS Learning the nature of an illness and the individual patient's responses.
Research - ANS Gathering of statistical data of clinical disorders, complications, therapies,
recovery, and deaths.
Auditing - ANS Objective, ongoing reviews to determine the degree to which quality
improvement standards are met.
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, The purpose of the electronic health record is: - ANS a. A positive impact on the quality of
patient care through interdisciplinary collaboration with improved data availability.
b. Improve patient safety through the use of clinical decision support.
According to HIPAA (Health Insurance Portability and Accountability Act), to eliminate barriers
that could delay care, providers are: - ANS a. Providers are required to notify patients of their
privacy policy and make a reasonable effort to get written acknowledgement of this notification.
b. HIPAA requires that disclosure or requests regarding health information are limited to the
minimum necessary.
The standards of documentation by the Joint Commission require: - ANS The standards of
documentation by The Joint Commission require documentation within the context of the
nursing process, as well as evidence of patient and family teaching and discharge planning.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Factual - ANS A factual record contains descriptive, objective information about what
a nurse sees, hears, feels, and smells.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Accurate - ANS An accurate record uses exact measurements, contains concise data,
contains only approved abbreviations, uses correct spelling, and identifies the date and
caregiver.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Complete - ANS A complete record contains all appropriate and essential
information.
Five important guidelines must be followed to ensure quality documentation and reporting.
Explain: Current - ANS Current records contain timely entries with immediate documentation
of information as it is collected from the patient.
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
