1|Page
NUR 209 Exam 2 Med-Surg 2 Newest 2026 Complete
Questions And Correct Detailed Answers (Verified
Answers) |Newest Exam Version!!!
Communication: Team Documentation & Reporting -
Answer--
Purposes of the patient record - Answer-1. Assessment →
comparison of objective and subjective assessment data
gathered by all team members
2. Care Planning → availability of all assessment data
allows nurses to more accurately develop nursing
diagnoses, goals, interventions and evaluation of patient
care
3. Legal Document → can be used to prove or disprove
injuries a patient incurred unintentionally or to implicate or
absolve improper care
4. Quality Assurance → determines whether certain care
standards were met & documented
,2|Page
▪Audits of patient records that are included are part of
accreditation requirements
▪Constantly revising certain procedures, policies based on
EBP (research)
5. Reimbursement → basis for decisions regarding care
and subsequent reimbursement to agency
▪Federal agencies of the state look at documentation for
reimbursement eligibility
▪Ex: look to see how many unreported cases of falls or
bed sores happened last year
▪Ex: if patient develops bed sore and no one checks it or
48 hours, then the nurse notices it and says "Yeah she
had that when they came in" but it was never documented
on date of admission→ hospital won't get reimbursed
6. Research → is carried out through patient records;
helps assure research outcomes are valid and reliable
7. Education → educational information that allows
students to relate patients' signs & symptoms,
interventions, and outcomes
,3|Page
▪Can't just hand over health care records to patient
because they may not understand them fully, so they must
get permission to read them and have a clinical or nurse
supervise them and review it in case they have any
questions
Principles of documentation - Answer-Handwritten, typed,
electronic communication/documentation is a form of
written communication and serves as a permanent record
of patient information and care provided by all members of
the healthcare team
1. Confidential: keep information private and legal
▪HIPAA ensures patients have the confidentiality of their
health care records - if the patient didn't sign to have
family members hear information, then the family must
leave when discussing care of plan or results with the
patient
▪ALL INFORMATION IS CONFIDENTIAL!
2. Accurate: all information was charted, there are no
spelling errors (PROOFREAD), and correct usage of
medical terms
, 4|Page
3. Concise and Complete: only use abbreviations
commonly accepted and approved,
▪Abbreviations are not used very often since they are
prone to mistakes and misinterpretation
▪Make sure decimals are in the correct spot, the 0 is
before the decimal but NEVER after a whole number in a
decimal
4. Objective: use direct quotes from the patient, no
interpretations from the nurse are included it is only
objective data
5. Organized and Timely: decreases the chance of
forgetting important information
▪Documentation serves as a permanent record of patient
information by all members of the healthcare team
▪Everything we write in the chart is proof we did it → in a
court of law the documentation is what is looked at
NUR 209 Exam 2 Med-Surg 2 Newest 2026 Complete
Questions And Correct Detailed Answers (Verified
Answers) |Newest Exam Version!!!
Communication: Team Documentation & Reporting -
Answer--
Purposes of the patient record - Answer-1. Assessment →
comparison of objective and subjective assessment data
gathered by all team members
2. Care Planning → availability of all assessment data
allows nurses to more accurately develop nursing
diagnoses, goals, interventions and evaluation of patient
care
3. Legal Document → can be used to prove or disprove
injuries a patient incurred unintentionally or to implicate or
absolve improper care
4. Quality Assurance → determines whether certain care
standards were met & documented
,2|Page
▪Audits of patient records that are included are part of
accreditation requirements
▪Constantly revising certain procedures, policies based on
EBP (research)
5. Reimbursement → basis for decisions regarding care
and subsequent reimbursement to agency
▪Federal agencies of the state look at documentation for
reimbursement eligibility
▪Ex: look to see how many unreported cases of falls or
bed sores happened last year
▪Ex: if patient develops bed sore and no one checks it or
48 hours, then the nurse notices it and says "Yeah she
had that when they came in" but it was never documented
on date of admission→ hospital won't get reimbursed
6. Research → is carried out through patient records;
helps assure research outcomes are valid and reliable
7. Education → educational information that allows
students to relate patients' signs & symptoms,
interventions, and outcomes
,3|Page
▪Can't just hand over health care records to patient
because they may not understand them fully, so they must
get permission to read them and have a clinical or nurse
supervise them and review it in case they have any
questions
Principles of documentation - Answer-Handwritten, typed,
electronic communication/documentation is a form of
written communication and serves as a permanent record
of patient information and care provided by all members of
the healthcare team
1. Confidential: keep information private and legal
▪HIPAA ensures patients have the confidentiality of their
health care records - if the patient didn't sign to have
family members hear information, then the family must
leave when discussing care of plan or results with the
patient
▪ALL INFORMATION IS CONFIDENTIAL!
2. Accurate: all information was charted, there are no
spelling errors (PROOFREAD), and correct usage of
medical terms
, 4|Page
3. Concise and Complete: only use abbreviations
commonly accepted and approved,
▪Abbreviations are not used very often since they are
prone to mistakes and misinterpretation
▪Make sure decimals are in the correct spot, the 0 is
before the decimal but NEVER after a whole number in a
decimal
4. Objective: use direct quotes from the patient, no
interpretations from the nurse are included it is only
objective data
5. Organized and Timely: decreases the chance of
forgetting important information
▪Documentation serves as a permanent record of patient
information by all members of the healthcare team
▪Everything we write in the chart is proof we did it → in a
court of law the documentation is what is looked at
