NU136
NU 136 EXAM 3 - Documentation, Nutrition, Nursing
Process, Complementary & Alternative Therapies
Complete Includes 100+ NCLEX Style Questions
and Answers 2026
Purposes of documentation
- written record
- evidence of care
- reimbursement of costs of care
- shows the use of the nursing process
- quality improvement
- research
- staff performance
- may be used as evidence in the court of law
Medical records
- Contains data about the patient's stay in the facility
- Held to privacy and confidentiality standards and laws
methods of documentation
- source oriented (narrative documentation)
- problem oriented
- focus documentation
- SOAP
- PIE (problem, identification, intervention)
- charting by exception
- computer assisted electronic documentation
- case management system (pathways)
source oriented charting
- also known as narrative charting
- organized according to source of information
- separate forms for each members of the healthcare team
- requires documentation of patient care in chronological order
NU136
,NU136
- gives a baseline condition for each shift
- includes aspects of all steps of the nursing process
- encourages documentation of both normal and abnormal findings, which may make it
difficult to identify relevant information
- requires more time to document
problem-oriented medical record (POMR) charting
- focuses on patient status rather than on medical or nursing care
- 5 parts: database, problem list, plan, progress notes, and discharge summary
- promotes a problem solving approach to care
- not in chronological order
- may make it difficult to track trends because data is fragmented
What information can be found in the database?
Initial assessment, general health history, findings of the physical examination, results of
diagnostic and laboratory tests, psychosocial information, nursing assessment, and the
patient's response to the illness or problem.
What is a problem list?
- A list of problems derived from the information in the database which is continually
updated with resolved problems archived by new problems added.
- Problems are listed in the chronologic order in which they were identified, not by
priority
- Both actual and potential problems are listed
What does planning entail?
- A three-part plan of care is devised based on the identified problems
- For each problem, there is a plan for diagnostic studies, a therapeutic plan, and a
patient education plan.
- The healthcare provider orders therapies for medical problems, and the nurse plans
care for nursing problems.
What is included in progress notes?
- Contains the assessments, plans, orders, treatments, and interventions of the
healthcare providers, nurses, and other members of the team
NU136
,NU136
- Notes are organized by problem number from the problem list
- Oftentimes, SOAP format is used
Discharge summary
A summary of the problems the patient had, how they were resolved, and the plan of
care after discharge.
SOAPIE
- Subjective
- Objective
- Assessment data
- Plan
- Implementation
- Evaluation
Focus charting
- directed at nursing diagnosis, patient problem, concern, sign, symptom, or event.
- very similar to POMR but removes the word "problem"
- DAR: data, action, response
- DAE: data, action, evaluation
- shortens documentation by using many flowsheets and checklists, but if the record is
not complete patient problems may be missed
Charting by exception
- based on the assumption that all standards of practice are carried out and met with a
normal or expected response unless otherwise documented
- a longhand note is only written when the standardized statement on the form is not
met
- highlights abnormal data and trends in the patient's condition
- eliminates duplication of charting.
- developed in the early 80's by a group of nurses in Wisconsin
- Nurses may become so used to not charting certain information that data can be easily
omitted
NU136
, NU136
computer-assisted charting
- electronic health record (EHR)
- computerized provider order entry (CPOE)
- documentation can be done immediately
- use of flow sheets with nursing interventions and expected outcomes
- others use a POMR format to produce a prioritized problem list
Electronic Health Record (EHR)
- A computerized, comprehensive record of a patient's history and care across all
facilities and admissions
- Provides vital information to healthcare personnel instantly so that they can
immediately review previous problems, treatments, and response
- As a legal record, the contents are confidential
- Written consent from the patient is required to share information with other people
not involved in patient care
- In all states, per federal law, patients do have the right to access information
contained in their record
- Record is divided into episodes of care - an episode of care is any time a patient
receives an assessment or intervention
- Contains laboratory results, diagnostic imaging reports, pathology reports, medication
administration, and other information from all care delivery settings
Computerized provider order entry (CPOE)
- A part of electronic documentation which helps speed up charting
- Orders entered into the computer directly by the prescribing healthcare provider are
automatically routed to appropriate clinical areas for action then automatically posted to
the electronic medication administration record (eMAR)
- Because the electronic order is always legible, this reduces transcribing errors (such as
handwriting and reading issues)
- Saves time
Case Management System Charting
NU136
NU 136 EXAM 3 - Documentation, Nutrition, Nursing
Process, Complementary & Alternative Therapies
Complete Includes 100+ NCLEX Style Questions
and Answers 2026
Purposes of documentation
- written record
- evidence of care
- reimbursement of costs of care
- shows the use of the nursing process
- quality improvement
- research
- staff performance
- may be used as evidence in the court of law
Medical records
- Contains data about the patient's stay in the facility
- Held to privacy and confidentiality standards and laws
methods of documentation
- source oriented (narrative documentation)
- problem oriented
- focus documentation
- SOAP
- PIE (problem, identification, intervention)
- charting by exception
- computer assisted electronic documentation
- case management system (pathways)
source oriented charting
- also known as narrative charting
- organized according to source of information
- separate forms for each members of the healthcare team
- requires documentation of patient care in chronological order
NU136
,NU136
- gives a baseline condition for each shift
- includes aspects of all steps of the nursing process
- encourages documentation of both normal and abnormal findings, which may make it
difficult to identify relevant information
- requires more time to document
problem-oriented medical record (POMR) charting
- focuses on patient status rather than on medical or nursing care
- 5 parts: database, problem list, plan, progress notes, and discharge summary
- promotes a problem solving approach to care
- not in chronological order
- may make it difficult to track trends because data is fragmented
What information can be found in the database?
Initial assessment, general health history, findings of the physical examination, results of
diagnostic and laboratory tests, psychosocial information, nursing assessment, and the
patient's response to the illness or problem.
What is a problem list?
- A list of problems derived from the information in the database which is continually
updated with resolved problems archived by new problems added.
- Problems are listed in the chronologic order in which they were identified, not by
priority
- Both actual and potential problems are listed
What does planning entail?
- A three-part plan of care is devised based on the identified problems
- For each problem, there is a plan for diagnostic studies, a therapeutic plan, and a
patient education plan.
- The healthcare provider orders therapies for medical problems, and the nurse plans
care for nursing problems.
What is included in progress notes?
- Contains the assessments, plans, orders, treatments, and interventions of the
healthcare providers, nurses, and other members of the team
NU136
,NU136
- Notes are organized by problem number from the problem list
- Oftentimes, SOAP format is used
Discharge summary
A summary of the problems the patient had, how they were resolved, and the plan of
care after discharge.
SOAPIE
- Subjective
- Objective
- Assessment data
- Plan
- Implementation
- Evaluation
Focus charting
- directed at nursing diagnosis, patient problem, concern, sign, symptom, or event.
- very similar to POMR but removes the word "problem"
- DAR: data, action, response
- DAE: data, action, evaluation
- shortens documentation by using many flowsheets and checklists, but if the record is
not complete patient problems may be missed
Charting by exception
- based on the assumption that all standards of practice are carried out and met with a
normal or expected response unless otherwise documented
- a longhand note is only written when the standardized statement on the form is not
met
- highlights abnormal data and trends in the patient's condition
- eliminates duplication of charting.
- developed in the early 80's by a group of nurses in Wisconsin
- Nurses may become so used to not charting certain information that data can be easily
omitted
NU136
, NU136
computer-assisted charting
- electronic health record (EHR)
- computerized provider order entry (CPOE)
- documentation can be done immediately
- use of flow sheets with nursing interventions and expected outcomes
- others use a POMR format to produce a prioritized problem list
Electronic Health Record (EHR)
- A computerized, comprehensive record of a patient's history and care across all
facilities and admissions
- Provides vital information to healthcare personnel instantly so that they can
immediately review previous problems, treatments, and response
- As a legal record, the contents are confidential
- Written consent from the patient is required to share information with other people
not involved in patient care
- In all states, per federal law, patients do have the right to access information
contained in their record
- Record is divided into episodes of care - an episode of care is any time a patient
receives an assessment or intervention
- Contains laboratory results, diagnostic imaging reports, pathology reports, medication
administration, and other information from all care delivery settings
Computerized provider order entry (CPOE)
- A part of electronic documentation which helps speed up charting
- Orders entered into the computer directly by the prescribing healthcare provider are
automatically routed to appropriate clinical areas for action then automatically posted to
the electronic medication administration record (eMAR)
- Because the electronic order is always legible, this reduces transcribing errors (such as
handwriting and reading issues)
- Saves time
Case Management System Charting
NU136
