ASSIGNMENTS EXAM SCRIPT 2026 FULL
QUESTIONS WITH CORRECT ANSWERS
◉ Five important guidelines must be followed to ensure quality
documentation and reporting. Explain: Current. Answer: Current
records contain timely entries with immediate documentation of
information as it is collected from the patient.
◉ Five important guidelines must be followed to ensure quality
documentation and reporting. Explain: Organized. Answer:
Organized records communicate information in a logical order.
◉ Narrative. Answer: Story-like format that has the tendency to have
repetitious information and be time consuming.
◉ Problem - oriented medical record (POMR). Answer: Database,
problem list, care plan, and progress notes.
◉ SOAP. Answer: Subjective, objective, assessment, and plan.
◉ SOAPIE. Answer: SOAP with intervention and evaluation added.
, ◉ PIE. Answer: Problem, intervention, and evaluation with a nursing
origin.
◉ Focus charting. Answer: Use of DAR (data, action, and response.)
◉ Progress notes. Answer: One of several formats or structured
notes within a POMR.
◉ Charting by exception. Answer: Focuses on deviations from the
established norm or abnormal findings; highlights trends and
changes.
◉ Case management. Answer: Incorporates a multidisciplinary
approach to documenting patient care.
◉ Critical pathways. Answer: Multidisciplinary care plans that
include patient problems, key interventions, and expected outcomes.
◉ Admission nursing history forms. Answer: Provides baseline data
to compare with changes in the patient's condition.
◉ Flow sheets. Answer: Provides current information that is
accessible to all members of the health care team.