VNSG 1304 Foundations Exam 2
Study Guide Questions and Correct
Answers | Latest Update
2024/2025
Problem Oriented Medical Record Charting (POMR)
• Problem solving approach to pt care
• 5 basic parts
Master01 | October, 2024/2025 | Latest update
, 1 | P a g e | © copyright 2024/2025 | Grade A+
- Database - Problem list - Plan - Progress notes - Discharge summary
Includes: SOAP, SOAPIE, SOAPIER, & PIE
P(roblem) I(nterventions) E(valuation)
*PIE*
• Follows nursing process
• Uses nursing diagnoses
• Places plan of care in nursing notes
• Differs from SOAP: doesn't require
narrative charting of assessment unless abnormal
Focus Charting (DARE)
• 3 components:
*D* - data
*A* - action
*R* - response
, *E* - evaluation
*Will see as DAE or DAR also*
Master01 | October, 2024/2025 | Latest update
1 | P a g e | © copyright 2024/2025 | Grade A+
Brevity in Charting
• Complete sentences not necessary
• Should start with capital/end with period
• Don't always have to say "Patient"
• Abbreviations per facility
• Must discern what is pertinent & what is
not *(requires critical thinking)
5 Steps of the nursing process and how they interact with each other-ADPIE
*A*ssessment - Collecting and examining data
*D*iagnosis - Analyzing data to identify health problems and strengths
*P*lanning -Developing a plan
, *I*mplementation - Putting the plan into action and observing initial
response
*E*valuation - Determining how well the plan has worked and whether
there is still a problem
Problem-Solving Method
*You encounter a problem* of some sort and begin to collect
information to see if you can understand the problem clearly.
*You study the information and identify just what the problem is* and what
resources might be able to help you.
Master01 | October, 2024/2025 | Latest update
Study Guide Questions and Correct
Answers | Latest Update
2024/2025
Problem Oriented Medical Record Charting (POMR)
• Problem solving approach to pt care
• 5 basic parts
Master01 | October, 2024/2025 | Latest update
, 1 | P a g e | © copyright 2024/2025 | Grade A+
- Database - Problem list - Plan - Progress notes - Discharge summary
Includes: SOAP, SOAPIE, SOAPIER, & PIE
P(roblem) I(nterventions) E(valuation)
*PIE*
• Follows nursing process
• Uses nursing diagnoses
• Places plan of care in nursing notes
• Differs from SOAP: doesn't require
narrative charting of assessment unless abnormal
Focus Charting (DARE)
• 3 components:
*D* - data
*A* - action
*R* - response
, *E* - evaluation
*Will see as DAE or DAR also*
Master01 | October, 2024/2025 | Latest update
1 | P a g e | © copyright 2024/2025 | Grade A+
Brevity in Charting
• Complete sentences not necessary
• Should start with capital/end with period
• Don't always have to say "Patient"
• Abbreviations per facility
• Must discern what is pertinent & what is
not *(requires critical thinking)
5 Steps of the nursing process and how they interact with each other-ADPIE
*A*ssessment - Collecting and examining data
*D*iagnosis - Analyzing data to identify health problems and strengths
*P*lanning -Developing a plan
, *I*mplementation - Putting the plan into action and observing initial
response
*E*valuation - Determining how well the plan has worked and whether
there is still a problem
Problem-Solving Method
*You encounter a problem* of some sort and begin to collect
information to see if you can understand the problem clearly.
*You study the information and identify just what the problem is* and what
resources might be able to help you.
Master01 | October, 2024/2025 | Latest update
