NURS 104L | Documentation & Charting Skills (2026/2027 Update)
WCU
1. When identifying the primary purpose of the medical record from a legal
perspective, which statement is most accurate?
A. It serves as a communication tool between the healthcare team members.
B. It is used by insurance companies to determine reimbursement rates.
C. It provides a permanent record of the patient’s condition and the care provided.
D. It acts as a primary source for clinical research and data collection.
Answer: C
Rationale: Legally, the medical record is the primary document used to prove that the
standard of care was met and reflects the patient’s status at any given time.
2. In the SOAPIE charting format, which component describes the patient’s
response to the interventions provided?
A. Assessment
B. Implementation
C. Evaluation
D. Subjective
Answer: C
Rationale: Evaluation is the specific phase where the nurse records the effectiveness of the
interventions and the patient’s reaction to the plan of care.
,3. A nurse is documenting in a patient’s electronic health record. Which of the
following entries demonstrates the best example of objective documentation?
A. The patient seems depressed and doesn’t want to talk today.
B. Patient appears to be in a lot of pain and is holding their side.
C. The patient was angry and uncooperative during the morning bath.
D. Patient ate 50% of lunch and stated, ‘I feel slightly nauseated.’
Answer: D
Rationale: Objective documentation uses measurable data and direct quotes, whereas
‘depressed’, ‘appears to be’, and ‘angry’ are subjective interpretations.
4. The Joint Commission ‘Do Not Use’ list forbids the use of which abbreviation
to prevent medication errors?
A. mL
B. NPO
C. mg
D. U (unit)
Answer: D
Rationale: The abbreviation ‘U’ can be mistaken for a zero, the number 4, or ‘cc’. It should
always be written as ‘unit’.
5. When a nurse makes a mistake while documenting in a paper-based medical
record, what is the correct action to take?
A. Use white-out to cover the error and write the correct information over it.
B. Rewrite the entire page to ensure the record is clean and legible.
C. Completely black out the error with a permanent marker.
D. Draw a single line through the error, write ‘error’ or ‘void’, and initial it.
Answer: D
Rationale: Proper correction involves a single line so the original entry is still visible,
ensuring transparency and legal integrity.
, 6. A nurse identifies that an incident report needs to be filed after a patient
falls. Where should the nurse document that an incident report was completed?
A. The incident report completion should not be mentioned in the patient’s medical record.
B. In the ‘Comments’ section of the physician’s orders.
C. In the nursing progress notes of the patient’s chart.
D. On the patient’s discharge summary.
Answer: A
Rationale: Incident reports are internal quality improvement documents and are not part
of the legal medical record; mentioning them in the chart makes them discoverable in a
lawsuit.
7. In DAR charting, what does the ‘R’ represent?
A. Response
B. Reason
C. Revision
D. Requirement
Answer: A
Rationale: DAR stands for Data (subjective/objective), Action (interventions), and
Response (patient outcome).
8. Which of the following is an advantage of Charting by Exception (CBE)?
A. It provides a comprehensive narrative of the patient’s entire day.
B. It eliminates the need for any standardized flow sheets.
C. It highlights abnormal findings and decreases charting time.
D. It is the most legally defensible form of documentation.
Answer: C
Rationale: CBE assumes all standards are met unless an exception (abnormality) is
documented, which streamlines the process.
WCU
1. When identifying the primary purpose of the medical record from a legal
perspective, which statement is most accurate?
A. It serves as a communication tool between the healthcare team members.
B. It is used by insurance companies to determine reimbursement rates.
C. It provides a permanent record of the patient’s condition and the care provided.
D. It acts as a primary source for clinical research and data collection.
Answer: C
Rationale: Legally, the medical record is the primary document used to prove that the
standard of care was met and reflects the patient’s status at any given time.
2. In the SOAPIE charting format, which component describes the patient’s
response to the interventions provided?
A. Assessment
B. Implementation
C. Evaluation
D. Subjective
Answer: C
Rationale: Evaluation is the specific phase where the nurse records the effectiveness of the
interventions and the patient’s reaction to the plan of care.
,3. A nurse is documenting in a patient’s electronic health record. Which of the
following entries demonstrates the best example of objective documentation?
A. The patient seems depressed and doesn’t want to talk today.
B. Patient appears to be in a lot of pain and is holding their side.
C. The patient was angry and uncooperative during the morning bath.
D. Patient ate 50% of lunch and stated, ‘I feel slightly nauseated.’
Answer: D
Rationale: Objective documentation uses measurable data and direct quotes, whereas
‘depressed’, ‘appears to be’, and ‘angry’ are subjective interpretations.
4. The Joint Commission ‘Do Not Use’ list forbids the use of which abbreviation
to prevent medication errors?
A. mL
B. NPO
C. mg
D. U (unit)
Answer: D
Rationale: The abbreviation ‘U’ can be mistaken for a zero, the number 4, or ‘cc’. It should
always be written as ‘unit’.
5. When a nurse makes a mistake while documenting in a paper-based medical
record, what is the correct action to take?
A. Use white-out to cover the error and write the correct information over it.
B. Rewrite the entire page to ensure the record is clean and legible.
C. Completely black out the error with a permanent marker.
D. Draw a single line through the error, write ‘error’ or ‘void’, and initial it.
Answer: D
Rationale: Proper correction involves a single line so the original entry is still visible,
ensuring transparency and legal integrity.
, 6. A nurse identifies that an incident report needs to be filed after a patient
falls. Where should the nurse document that an incident report was completed?
A. The incident report completion should not be mentioned in the patient’s medical record.
B. In the ‘Comments’ section of the physician’s orders.
C. In the nursing progress notes of the patient’s chart.
D. On the patient’s discharge summary.
Answer: A
Rationale: Incident reports are internal quality improvement documents and are not part
of the legal medical record; mentioning them in the chart makes them discoverable in a
lawsuit.
7. In DAR charting, what does the ‘R’ represent?
A. Response
B. Reason
C. Revision
D. Requirement
Answer: A
Rationale: DAR stands for Data (subjective/objective), Action (interventions), and
Response (patient outcome).
8. Which of the following is an advantage of Charting by Exception (CBE)?
A. It provides a comprehensive narrative of the patient’s entire day.
B. It eliminates the need for any standardized flow sheets.
C. It highlights abnormal findings and decreases charting time.
D. It is the most legally defensible form of documentation.
Answer: C
Rationale: CBE assumes all standards are met unless an exception (abnormality) is
documented, which streamlines the process.
