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NUR 209 Exam 2 Fortis Med Surg II
2026/2027 Questions with Verified
Answers and Detailed Rationales Grade A
1. What are the purposes of the patient record?
Correct 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; 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
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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 for 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; 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
Rationale:
1. Patient records serve multiple essential functions in healthcare delivery.
2. Assessment data from all team members provides a complete picture of
patient status.
3. Care planning relies on accurate documentation to develop appropriate
nursing diagnoses and interventions.
4. Legal documentation can prove or disprove allegations of improper care.
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5. Quality assurance audits ensure standards are met and drive evidence-
based practice improvements.
6. Reimbursement depends on proper documentation of care, including
prevention of hospital-acquired conditions.
7. Research uses patient records to validate outcomes and identify best
practices.
8. Education allows students to learn from real patient cases under supervised
conditions.
2. What are the principles of documentation?
Correct 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; 3.
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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; Reporting is a form of verbal communication that
takes place to show patient care → should happen face to face so you can
ask questions!! More than 70% of sentinel events occur due to
miscommunication.
Rationale:
1. Confidentiality under HIPAA protects patient privacy and is legally required.
2. Accuracy prevents errors; proofreading eliminates spelling mistakes that
could change meaning.
3. Concise and complete documentation uses only approved abbreviations;
decimals must be correct (0 before decimal, never after a whole number).
NUR 209 Exam 2 Fortis Med Surg II
2026/2027 Questions with Verified
Answers and Detailed Rationales Grade A
1. What are the purposes of the patient record?
Correct 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; 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
,2|Page
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 for 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; 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
Rationale:
1. Patient records serve multiple essential functions in healthcare delivery.
2. Assessment data from all team members provides a complete picture of
patient status.
3. Care planning relies on accurate documentation to develop appropriate
nursing diagnoses and interventions.
4. Legal documentation can prove or disprove allegations of improper care.
,3|Page
5. Quality assurance audits ensure standards are met and drive evidence-
based practice improvements.
6. Reimbursement depends on proper documentation of care, including
prevention of hospital-acquired conditions.
7. Research uses patient records to validate outcomes and identify best
practices.
8. Education allows students to learn from real patient cases under supervised
conditions.
2. What are the principles of documentation?
Correct 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; 3.
, 4|Page
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; Reporting is a form of verbal communication that
takes place to show patient care → should happen face to face so you can
ask questions!! More than 70% of sentinel events occur due to
miscommunication.
Rationale:
1. Confidentiality under HIPAA protects patient privacy and is legally required.
2. Accuracy prevents errors; proofreading eliminates spelling mistakes that
could change meaning.
3. Concise and complete documentation uses only approved abbreviations;
decimals must be correct (0 before decimal, never after a whole number).
