EHR EXAM 1 HIGH-YIELD CLINICAL
DOCUMENTATION AND DATA ENTRY
SUMMARY 2026
◉ POMR.
Answer: problem-oriented medical record - organized through
problem solving system/ accumulated date prioritizing health
problems addressed
◉ SOAP.
Answer: Subjective, Objective, Assessment, Plan, (Evaluation)
◉ SOAPIER.
Answer: subjective, objective, assessment, plan, intervention,
evaluation, revision
◉ Focus Charting.
Answer: Uses the nursing process and the more positive concept of
the patient's needs rather than medical diagnoses and problems
◉ DARE.
Answer: Data, Action, Response (& Evaluation), Education
, ◉ CBE.
Answer: Charting by Exception - notes only made following
additional treatments and changes in patient condition following
previously charted assessments
◉ PIE charting.
Answer: problem, intervention, evaluation
◉ Incident Reports.
Answer: documents events inconsistent with routine operation -
give objective information/ do not admit liability
◉ 24 hour patient care reports.
Answer: documents ADLs
◉ Acuity Charting.
Answer: uses a score that rates each patient by severity of illness (1
is high, 5 is low)
◉ Discharge Summary.
Answer: Provides important information pertaining to patients
continued health care following discharge
DOCUMENTATION AND DATA ENTRY
SUMMARY 2026
◉ POMR.
Answer: problem-oriented medical record - organized through
problem solving system/ accumulated date prioritizing health
problems addressed
◉ SOAP.
Answer: Subjective, Objective, Assessment, Plan, (Evaluation)
◉ SOAPIER.
Answer: subjective, objective, assessment, plan, intervention,
evaluation, revision
◉ Focus Charting.
Answer: Uses the nursing process and the more positive concept of
the patient's needs rather than medical diagnoses and problems
◉ DARE.
Answer: Data, Action, Response (& Evaluation), Education
, ◉ CBE.
Answer: Charting by Exception - notes only made following
additional treatments and changes in patient condition following
previously charted assessments
◉ PIE charting.
Answer: problem, intervention, evaluation
◉ Incident Reports.
Answer: documents events inconsistent with routine operation -
give objective information/ do not admit liability
◉ 24 hour patient care reports.
Answer: documents ADLs
◉ Acuity Charting.
Answer: uses a score that rates each patient by severity of illness (1
is high, 5 is low)
◉ Discharge Summary.
Answer: Provides important information pertaining to patients
continued health care following discharge
