© 2026/27 Qs & Ans
Nursing Documentation and Charting Exam
Questions And 100% Correct Answers With
Verified Rationales | Instant Pdf Download
1. What is the primary purpose of nursing documentation?
A. To impress healthcare providers
B. To provide a legal record of patient care
C. To reduce nursing workload
D. To replace verbal communication
Answer: B. To provide a legal record of patient care
Rationale: Documentation serves as a legal, clinical, and communication
record of care provided.
2. Which principle is essential in nursing documentation?
A. Vagueness
B. Timeliness
C. Guesswork
D. Opinion-based writing
Answer: B. Timeliness
Rationale: Documentation should be completed as soon as possible after
care is provided.
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, © 2026/27 Qs & Ans
3. Which documentation entry is most appropriate?
A. “Patient seems fine.”
B. “Patient reports pain 8/10 in abdomen.”
C. “Patient is okay.”
D. “Patient looks better today.”
Answer: B. “Patient reports pain 8/10 in abdomen.”
Rationale: Accurate documentation includes measurable or patient-
reported data.
4. Which statement is subjective documentation?
A. Temperature 101°F
B. Blood pressure 120/80
C. “I feel nauseated”
D. Oxygen saturation 96%
Answer: C. “I feel nauseated”
Rationale: Subjective data comes from the patient’s own experience.
5. Which is an example of objective documentation?
A. “I feel dizzy”
B. “Pain is bad”
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, © 2026/27 Qs & Ans
C. Heart rate 110 bpm
D. “I feel weak”
Answer: C. Heart rate 110 bpm
Rationale: Objective data is measurable and observable.
6. Which documentation error must be avoided?
A. Clear handwriting
B. Use of abbreviations approved by facility
C. Late entry corrections properly labeled
D. Altering records without documentation
Answer: D. Altering records without documentation
Rationale: Altering records is illegal and unethical.
7. What is charting by exception?
A. Documenting only abnormal findings
B. Documenting everything in detail
C. Skipping documentation
D. Writing opinions only
Answer: A. Documenting only abnormal findings
Rationale: Normal findings are assumed unless documented otherwise.
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, © 2026/27 Qs & Ans
8. Which action ensures confidentiality in documentation?
A. Sharing login credentials
B. Logging out after use
C. Leaving charts open
D. Discussing patient records publicly
Answer: B. Logging out after use
Rationale: Protects patient privacy and data security.
9. Which abbreviation is acceptable in documentation?
A. U for unit (per facility policy)
B. “QD” if not approved
C. “MS” for morphine sulfate
D. Non-standard abbreviations
Answer: A. U for unit (per facility policy)
Rationale: Only approved abbreviations should be used.
10. Which documentation entry is most accurate?
A. “Patient is fine.”
B. “Patient appears better.”
C. “Patient ambulated 20 feet with walker, steady gait.”
D. “Patient doing okay.”
Answer: C. “Patient ambulated 20 feet with walker, steady gait.”
4
Nursing Documentation and Charting Exam
Questions And 100% Correct Answers With
Verified Rationales | Instant Pdf Download
1. What is the primary purpose of nursing documentation?
A. To impress healthcare providers
B. To provide a legal record of patient care
C. To reduce nursing workload
D. To replace verbal communication
Answer: B. To provide a legal record of patient care
Rationale: Documentation serves as a legal, clinical, and communication
record of care provided.
2. Which principle is essential in nursing documentation?
A. Vagueness
B. Timeliness
C. Guesswork
D. Opinion-based writing
Answer: B. Timeliness
Rationale: Documentation should be completed as soon as possible after
care is provided.
1
, © 2026/27 Qs & Ans
3. Which documentation entry is most appropriate?
A. “Patient seems fine.”
B. “Patient reports pain 8/10 in abdomen.”
C. “Patient is okay.”
D. “Patient looks better today.”
Answer: B. “Patient reports pain 8/10 in abdomen.”
Rationale: Accurate documentation includes measurable or patient-
reported data.
4. Which statement is subjective documentation?
A. Temperature 101°F
B. Blood pressure 120/80
C. “I feel nauseated”
D. Oxygen saturation 96%
Answer: C. “I feel nauseated”
Rationale: Subjective data comes from the patient’s own experience.
5. Which is an example of objective documentation?
A. “I feel dizzy”
B. “Pain is bad”
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, © 2026/27 Qs & Ans
C. Heart rate 110 bpm
D. “I feel weak”
Answer: C. Heart rate 110 bpm
Rationale: Objective data is measurable and observable.
6. Which documentation error must be avoided?
A. Clear handwriting
B. Use of abbreviations approved by facility
C. Late entry corrections properly labeled
D. Altering records without documentation
Answer: D. Altering records without documentation
Rationale: Altering records is illegal and unethical.
7. What is charting by exception?
A. Documenting only abnormal findings
B. Documenting everything in detail
C. Skipping documentation
D. Writing opinions only
Answer: A. Documenting only abnormal findings
Rationale: Normal findings are assumed unless documented otherwise.
3
, © 2026/27 Qs & Ans
8. Which action ensures confidentiality in documentation?
A. Sharing login credentials
B. Logging out after use
C. Leaving charts open
D. Discussing patient records publicly
Answer: B. Logging out after use
Rationale: Protects patient privacy and data security.
9. Which abbreviation is acceptable in documentation?
A. U for unit (per facility policy)
B. “QD” if not approved
C. “MS” for morphine sulfate
D. Non-standard abbreviations
Answer: A. U for unit (per facility policy)
Rationale: Only approved abbreviations should be used.
10. Which documentation entry is most accurate?
A. “Patient is fine.”
B. “Patient appears better.”
C. “Patient ambulated 20 feet with walker, steady gait.”
D. “Patient doing okay.”
Answer: C. “Patient ambulated 20 feet with walker, steady gait.”
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