Charting, and what it costs

Every question in this set, with the answer

Use this to review after you finish — or instead of the timed version, if you would rather just read.

1. At 1400, you documented an IV site without redness or swelling and no reported site pain, with a plan to monitor. At 1500, you reassess: no redness, swelling, or leakage is observed, and the patient again denies site pain. Which separate follow-up entry best documents the completed reassessment?

   1. 1500—IV site stable and patient comfortable. Monitoring continued as planned.
   2. 1500—IV site reassessed; no redness, swelling, or leakage observed. Patient denies site pain.
   3. 1500—Will continue monitoring IV site for redness, swelling, leakage, and site pain.
   4. 1400–1500—IV site remained without redness, swelling, leakage, or pain throughout monitoring.

   Answer: 1500—IV site reassessed; no redness, swelling, or leakage observed. Patient denies site pain.

   The correct entry records specific findings from the completed 1500 reassessment. The other entries substitute unsupported labels for findings, describe future monitoring rather than completed care, or imply continuous observation between two timed checks.

2. At 0830, a patient declines a shower, reporting fatigue. You offer a seated wash at the bedside and assist with washing the face and upper body; the patient declines the remaining hygiene care. You plan to reoffer it after rest. Which statements accurately contribute to documentation of this encounter? Select all that apply.

   1. 0830—Declined shower, reporting fatigue.
   2. 0830—Declined all hygiene care because of fatigue.
   3. Offered seated wash at bedside. Accepted assistance washing face and upper body; declined remaining hygiene care.
   4. 0830—Hygiene completed with assistance after shower was declined.
   5. Plan to reoffer remaining hygiene care after rest.

   Answer: 0830—Declined shower, reporting fatigue., Offered seated wash at bedside. Accepted assistance washing face and upper body; declined remaining hygiene care., Plan to reoffer remaining hygiene care after rest.

   The selected statements identify the care declined, the patient's reason, the alternative offered and accepted, and the follow-up plan. Saying all hygiene was declined erases the care accepted, while saying hygiene was completed overstates what occurred.

3. At 1410, you page Dr. Lee about urine output of 20 mL over the past 2 hours. At 1420, you speak with Dr. Lee, report the urine output and BP 118/70, and receive no new orders. Which documentation best preserves the distinction between these events?

   1. 1410—Dr. Lee notified of urine output of 20 mL over past 2 hours and BP 118/70. No new orders received.
   2. 1420—Provider aware of urine output of 20 mL over past 2 hours and BP 118/70. No new orders received.
   3. 1410—Paged Dr. Lee regarding urine output of 20 mL over past 2 hours. Separate 1420 entry—Spoke with Dr. Lee; reported urine output and BP 118/70. No new orders received.
   4. 1410—Paged Dr. Lee regarding urine output of 20 mL over past 2 hours; no new orders received. Separate 1420 entry—Provider aware; BP 118/70.

   Answer: 1410—Paged Dr. Lee regarding urine output of 20 mL over past 2 hours. Separate 1420 entry—Spoke with Dr. Lee; reported urine output and BP 118/70. No new orders received.

   The correct documentation separates the page from the later conversation and records the information communicated and the response at the appropriate time. The alternatives merge events, leave the actual communication unclear, or attach the absence of new orders to the page rather than the completed conversation.

4. Before signing an 0800 note, you review template statements reading 'Fall precautions maintained at all times' and 'Patient understands instructions.' At 0800, you found the bed low and locked with the call light within reach, reviewed calling for assistance before standing, and observed the patient demonstrate call-light use. This entry documents only that check. Which revisions best match what you assessed and did? Select all that apply.

   1. Keep 'Fall precautions maintained at all times' because the bed and call light were correctly positioned at 0800.
   2. Replace the broad precautions statement with the 0800 findings about bed position and call-light placement.
   3. Document the instruction reviewed and the patient's demonstration of call-light use at 0800.
   4. Replace 'at all times' with 'throughout the shift' to make the period more specific.
   5. Keep only 'Patient understands instructions' because documenting that teaching occurred is enough to show understanding.

   Answer: Replace the broad precautions statement with the 0800 findings about bed position and call-light placement., Document the instruction reviewed and the patient's demonstration of call-light use at 0800.

   The selected revisions document the timed findings, teaching, and observed demonstration rather than relying on template conclusions. Neither 'at all times' nor 'throughout the shift' is established by one check, and 'understands' alone omits how understanding was checked. The 0800 entry also does not replace required documentation of ongoing checks or supervision.

5. At 1030, you complete a dressing change. The patient rated pain 3/10 before the procedure and 4/10 afterward, and you observed no bleeding during the dressing change. Your draft says 'Tolerated dressing change well.' Which revision best documents the patient's response without claiming more than you assessed?

   1. 1030—Dressing change tolerated well; pain assessed before and after, with no bleeding observed.
   2. 1030—Dressing change completed. Pain remained stable; no bleeding observed during the procedure.
   3. 1030—Dressing change completed without complications; patient comfortable afterward.
   4. 1030—Dressing change completed. Patient rated pain 3/10 before procedure and 4/10 afterward. No bleeding observed during dressing change.

   Answer: 1030—Dressing change completed. Patient rated pain 3/10 before procedure and 4/10 afterward. No bleeding observed during dressing change.

   The correct entry gives the actual before-and-after pain ratings and the observed absence of bleeding. The first two alternatives omit the pain measurements in favor of general wording, while the third adds broader claims about comfort and complications that these findings do not establish.

6. At 0015 on 09/12/2026, you are documenting assistance with ambulation provided at 1930 on 09/11/2026. The care description is accurate. Which opening most clearly distinguishes when the care happened from when you documented it?

   1. 09/11/2026 1930 — Late entry: Assisted patient to ambulate.
   2. 09/12/2026 0015 — Late entry for care provided 09/11/2026 at 1930:
   3. 09/12/2026 0015 — Late entry for assistance with ambulation at 1930:
   4. 09/12/2026 0015 — Late entry for assistance with ambulation during the previous evening:

   Answer: 09/12/2026 0015 — Late entry for care provided 09/11/2026 at 1930:

   The correct opening explicitly identifies both dates and both times. The other openings either present the care time as the entry time, omit the care date, or replace a known care time with a less precise description.

7. At 0910 on 09/12/2026, you remember reinforcing a right forearm dressing with gauze during the 1500–2300 shift on 09/11/2026. You cannot recall the exact time or whether you assessed the surrounding skin. Which choices keep the late entry within what you can accurately support? Select all that apply.

   1. Identify the 1500–2300 shift on 09/11/2026 and state that the exact time is not recalled.
   2. Enter 1800 as the care time because it is a reasonable estimate based on your usual routine.
   3. Include that the surrounding skin was intact because checking it is part of your usual dressing routine.
   4. Describe the recalled dressing reinforcement with gauze without adding surrounding-skin findings.
   5. Use “Assessment unchanged” instead of specific skin findings because you cannot recall the details.

   Answer: Identify the 1500–2300 shift on 09/11/2026 and state that the exact time is not recalled., Describe the recalled dressing reinforcement with gauze without adding surrounding-skin findings.

   The known shift and the recalled dressing care are supportable; an exact time and surrounding-skin findings are not. Choosing 1800 manufactures precision, while routine skin findings or “Assessment unchanged” would imply an assessment you cannot reliably reconstruct.

8. At 0920 on 09/12/2026, you discover that your nursing note entered at 1810 on 09/11/2026 incorrectly identifies the left forearm. You accurately remember reinforcing the right forearm dressing. Which actions belong in the correction process? Select all that apply.

   1. Use the facility’s approved correction workflow and preserve the original entry.
   2. Add a separate late entry saying “Right forearm dressing reinforced” without identifying the error in the earlier note.
   3. Identify the note entered on 09/11/2026 at 1810 and state that the dressing reinforced was on the right forearm, not the left.
   4. Replace the incorrect location directly in the signed note so that only the accurate wording remains.
   5. Authenticate the correction with your own credentials.

   Answer: Use the facility’s approved correction workflow and preserve the original entry., Identify the note entered on 09/11/2026 at 1810 and state that the dressing reinforced was on the right forearm, not the left., Authenticate the correction with your own credentials.

   The correction should preserve the original, identify exactly which entry and fact are being corrected, and be authenticated by you. An unlinked late entry does not explain the earlier error, while silently replacing the location removes the correction history.

9. At the end of your shift, you find a missing medication entry in the MAR. The gap leaves doubt about whether a dose was given. Which response best addresses the documentation gap?

   1. Write a narrative note describing the uncertainty and rely on that note to resolve the MAR gap.
   2. Complete the MAR using the scheduled medication time and label the entry as delayed.
   3. Tell the current care team about the uncertainty and address the gap through the approved MAR process.
   4. Use the approved MAR process to document the uncertainty and treat the updated record as sufficient notification to the team.

   Answer: Tell the current care team about the uncertainty and address the gap through the approved MAR process.

   The uncertainty needs to be communicated to the current care team, and the MAR gap should be addressed through the approved process. A narrative note alone may not resolve the gap, a scheduled time does not establish that administration occurred, and updating the record does not replace the conversation.

10. After finishing your shift, you remember care you provided but did not document. You are now off duty, and the encounter is closed. What is the best next step for completing the record?

    1. Wait until your next scheduled shift so you can attempt the entry through your usual workflow.
    2. Contact the appropriate supervisor or health information management team to arrange an authorized way to complete the record.
    3. Ask an on-duty nurse to enter your missed care under that nurse’s credentials so the record is completed sooner.
    4. Write down the details now and plan to enter them within an assumed 24-hour grace period.

    Answer: Contact the appropriate supervisor or health information management team to arrange an authorized way to complete the record.

    An off-duty or closed-encounter issue should be routed to the appropriate supervisor or health information management team for an authorized process. Waiting for the next shift or assuming a 24-hour grace period does not follow that direction, and another nurse’s credentials do not substitute for authenticating your own addition.

11. At 1400, a patient declined a full left-side turn because of left hip pain but accepted an assisted weight shift and heel off-loading. After analgesic administration, pain was 3/10 and the patient accepted assisted repositioning at 1435. Which entry best preserves the distinction between care declined and care accepted?

    1. 1400: Refused left-side turn because of hip pain. 1435: Accepted repositioning after analgesic administration; see MAR.
    2. 1400: Repositioning postponed until after pain medication. 1435: Pain 3/10; assisted repositioning completed.
    3. 1400: Declined full left-side turn because of hip pain; accepted assisted weight shift and heel off-loading. 1435: Pain 3/10; accepted assisted repositioning.
    4. 1400: Turning education provided; patient requested analgesic before repositioning. 1435: Pain improved and patient agreed to recommended repositioning.

    Answer: 1400: Declined full left-side turn because of hip pain; accepted assisted weight shift and heel off-loading. 1435: Pain 3/10; accepted assisted repositioning.

    The correct entry distinguishes the full turn declined from the pressure-relief measures accepted, then records the later repositioning. The other entries omit the initial accepted care, which can make a partial refusal look like postponement of all repositioning.

12. At 0900, a patient declined scheduled enoxaparin, reporting painful bruising after previous injections. You reviewed its purpose for blood-clot prevention during reduced mobility and the risk of a clot without recommended prophylaxis. The patient explained the medication’s purpose and continued to decline. Which entry best documents the patient's response without overstating understanding?

    1. Patient verbalized understanding of medication education and declined the scheduled dose because of bruising after previous injections.
    2. Patient explained that the medication helps prevent blood clots during reduced mobility and continued to decline, reporting painful bruising after previous injections.
    3. Patient understands all risks of declining enoxaparin and chose not to receive the scheduled dose because of previous injection bruising.
    4. Medication education completed, including purpose and clot risk. Patient’s concern about painful bruising documented; scheduled dose declined and not administered.

    Answer: Patient explained that the medication helps prevent blood clots during reduced mobility and continued to decline, reporting painful bruising after previous injections.

    Recording what the patient explained back shows the specific understanding demonstrated. “Verbalized understanding” is nonspecific, “understands all risks” overstates the evidence, and documenting completed education without the patient's explanation leaves out the response.

13. At 0910, you notified Dr. Chen that the patient declined enoxaparin because of painful bruising after previous injections. At 0915, Dr. Chen responded with a plan for bedside review of prophylaxis options. That review is still pending when you finish your entry. Which details should you include? Select all that apply.

    1. 0910: Dr. Chen notified of the declined dose and the patient's reported concern about painful bruising.
    2. 0915: Prophylaxis options reviewed with Dr. Chen; bedside discussion with the patient to follow.
    3. 0915: Dr. Chen responded and plans bedside review of prophylaxis options.
    4. Refusal communication completed with provider response; no further follow-up outstanding.
    5. Bedside review of prophylaxis options remains pending.

    Answer: 0910: Dr. Chen notified of the declined dose and the patient's reported concern about painful bruising., 0915: Dr. Chen responded and plans bedside review of prophylaxis options., Bedside review of prophylaxis options remains pending.

    The selected details identify whom you notified, when, what you reported, the response, and the unresolved next step. The other choices turn a planned review into a completed review or incorrectly close follow-up before that review occurs.

14. At 1742, a patient declined to sign the AMA form and continued toward the exit after you asked them to wait for a clinician discussion. The patient departed at 1744 before that discussion, repeat vital signs, or written instructions could be completed. Which statements accurately document the unfinished portions of this encounter? Select all that apply.

    1. Leaving risks reviewed; patient continued toward the exit despite counseling.
    2. Patient departed at 1744 before clinician discussion could be completed.
    3. Patient understood the consequences of leaving and declined further discussion.
    4. Repeat vital signs and written instructions were not completed before departure.
    5. Patient declined written instructions when leaving at 1744.

    Answer: Patient departed at 1744 before clinician discussion could be completed., Repeat vital signs and written instructions were not completed before departure.

    The selected statements clearly identify what could not be completed before departure. Walking away does not establish that counseling occurred or understanding was demonstrated, and unfinished instructions should not be documented as instructions the patient explicitly declined.

15. At 1615, you were present while Dr. Patel recommended continued evaluation and discussed possible heart attack, serious deterioration, and death if evaluation or treatment was delayed. The patient explained that initial testing had not ruled out a heart attack and continued to request departure. Dr. Patel assessed decision-making capacity. Which entry best distinguishes your observations from the clinician's assessment?

    1. 1615: Dr. Patel discussed possible heart attack, serious deterioration, and death with delayed evaluation or treatment; RN present. Patient explained that initial testing had not ruled out a heart attack and continued to request departure. Dr. Patel assessed decision-making capacity; see provider note.
    2. 1615: I explained possible heart attack, serious deterioration, and death with delayed evaluation or treatment. Patient explained that initial testing had not ruled out a heart attack and continued to request departure. Decision-making capacity intact; Dr. Patel aware.
    3. 1615: Dr. Patel discussed leaving risks; RN witnessed discussion. Patient understands all risks and is competent to leave but continues to request departure. See provider note for the discussion and assessment.
    4. 1615: Risks discussed and decision-making capacity assessed at bedside. Patient explained that initial testing had not ruled out a heart attack and continued to request departure. See provider note for discussion and assessment details.

    Answer: 1615: Dr. Patel discussed possible heart attack, serious deterioration, and death with delayed evaluation or treatment; RN present. Patient explained that initial testing had not ruled out a heart attack and continued to request departure. Dr. Patel assessed decision-making capacity; see provider note.

    The correct entry names the person who explained the risks, identifies your presence, records the patient's response, and attributes the capacity assessment to Dr. Patel. The other entries misattribute the explanation, overstate understanding and capacity, or leave unclear who conducted and witnessed the discussion.