01
True or false
1 point
A nurse documents an urgent change in a patient's condition. If the chart entry is complete, no separate prompt notification to the appropriate clinician is needed.
Free Practice Quiz Question List
8 Documentation and Continuity of Care Online Quiz Questions
Use this free practice quiz with 20 questions to review 8 Documentation and Continuity of Care, test your knowledge, and prepare for your next test or exam.
20 questions
02
Choose one
1 point
A patient says, “I feel dizzy when I stand.” Which entry best documents this information objectively?
- A
Patient states, “I feel dizzy when I stand.”
- B
Patient is unstable when standing.
- C
Patient appears to be exaggerating dizziness.
- D
Patient has a poor attitude about standing.
03
Fill in the blank
1 point
To help other clinicians make decisions using current information, document care .
04
Written response
1 point
What four-letter framework organizes verbal communication into Situation, Background, Assessment, and Recommendation or request?
05
True or false
1 point
Under HIPAA, the minimum-necessary standard generally applies to disclosures to or requests by a healthcare provider for treatment purposes.
- A
True
- B
False
06
Choose one
1 point
A nurse discovers an error in a signed health-record entry. Which action follows sound documentation practice?
- A
Delete the original entry so only the corrected information remains.
- B
Preserve the original entry and add a correction or addendum using the approved process.
- C
Backdate the correction to make it appear contemporaneous.
- D
Obscure the original entry and replace it without noting the change.
07
Written response
1 point
What documentation-quality term describes entries authenticated with the clinician's own authorized login or signature?
08
Fill in the blank
1 point
In the I-PASS framework, the final component is by the receiver.
09
Choose all
1 point
A clinician is preparing a handoff to another unit. Which details should be included to support safe continuity of care? Select all that apply.
- A
Confirm the patient's identity.
- B
Summarize current status and relevant background.
- C
Highlight safety risks.
- D
Describe pending tasks and when they are due.
- E
Explain changes that should prompt reassessment or escalation.
- F
Include unrelated personal opinions about other team members.
- G
Leave next steps unspecified so the receiver can decide without a handoff plan.
10
Choose one
1 point
A patient develops a time-sensitive change in condition. What should the nurse do after recognizing the change?
- A
Enter a detailed chart note and wait for the next routine handoff.
- B
Promptly notify the appropriate clinician, clearly state the concern, and follow escalation procedures.
- C
Ask a colleague to mention the change if they happen to speak with the clinician.
- D
Wait to see whether the patient improves before communicating the change.
11
Choose all
1 point
After reporting a patient's worsening condition, which details should the nurse document according to policy? Select all that apply.
- A
The relevant assessment and the time it was made.
- B
Whom you contacted and when.
- C
The information you communicated.
- D
Instructions or orders received.
- E
Actions taken.
- F
The patient's response.
- G
Only the fact that a phone call occurred, without any other relevant details.
12
Choose one
1 point
A staff member is considering opening a patient's record. Which action is consistent with responsible record use?
- A
Access the record only if there is an authorized work-related purpose.
- B
Open the record to satisfy personal curiosity as long as no information is shared.
- C
Use a personal messaging account to send patient information to a coworker.
- D
Leave a patient's information visible on a screen when stepping away.
13
Open ended
1 point
A nurse is preparing a current note and finds that details from an earlier assessment have been copied forward. Some details may have changed. What should the nurse do before signing, and why?
14
Choose one
1 point
You notice that a chart entry you made contains an error. What should you do?
- A
Delete the original entry and write a replacement note.
- B
Follow the approved correction process so the original entry is preserved and the correction is visible.
- C
Change the entry date so it matches when the care occurred.
- D
Ask a coworker to edit the entry under their own login.
15
Choose one
1 point
A colleague asks you to look up a patient's chart even though you are not involved in the patient's care and have no work-related reason to access it. What is the appropriate response?
- A
Open the chart because employees may review any record in the system.
- B
Open the chart if a coworker says the patient is interesting.
- C
Access the chart only if you have an authorized work-related purpose.
- D
Access the chart as long as you do not print or share its contents.
16
True or false
1 point
Under HIPAA, the minimum-necessary standard applies to disclosures of protected health information to a healthcare provider for treatment purposes.
- A
True
- B
False
17
Choose one
1 point
When using SBAR to report a patient's worsening breathing, which component communicates your findings and concern about the patient's condition?
- A
Situation
- B
Assessment
- C
Background
- D
Recommendation or request
18
Written response
1 point
A hospital record entry is legible, complete, dated, and timed, but it has not been verified as belonging to its author. According to CMS guidance described in the material, which documentation attribute is missing?
19
Choose one
1 point
After reporting a time-sensitive change in a patient's condition, which set of details should you document according to policy?
- A
Document the assessment and its time, whom you contacted and when, the information communicated, instructions or orders received, actions taken, and the patient's response.
- B
Record only that a phone call occurred, without identifying its content or the patient's response.
- C
Wait until the next shift to document the report, even if details may be forgotten.
- D
Document only instructions received, leaving out the assessment, its time, and the patient's response.
20
Written response
1 point
During an I-PASS handoff, which element gives the receiving clinician a chance to summarize the information and confirm the plan?