1|Page
NURS 136 EXAM 3 NEWEST ACTUAL EXAM
COMPLETE QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||LATEST VERSION!!!
Purposes of documentation - Answer--written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
Medical record - Answer--Contains data about patient's
stay in a facility
-Only health care professionals directly caring for the
patient, or those involved in research or teaching, should
have access to the chart
-Patient information should not be discussed with anyone
not directly involved in the patient's care
Methods of documentation - Answer-1. Source-
oriented/narrative records
,2|Page
2. Problem-oriented medical records
3. Focus charting
4. Charting by exception
5. Case management model
6. Computerized documentation/Electronic health records
(EHRs)
Advantage and disadvantage of Source-Oriented MR/
Narrative - Answer-Pro:
-info of pt in chronological order
-pt condition noted each shift
-steps of nursing process
Con:
-normal & abnormal findings
-extensive documentation by staff
-lengthy entries
Source oriented / narrative charting - Answer--organized
according to source info
-separate forms for nurses/physicians/etc.
,3|Page
problem-oriented medical record (POMR) - Answer--
Focuses on pt status
-contains 5 basic parts:
1. database
2. problem list
3.the plan
4. the progress notes
5. discharge summary
-uses SOAP
Advantages & disadvantages of Problem-oriented MR -
Answer-pros:
-improves continuity of care & communication by keeping
data relevant
-easy auditing of pt MR for staff evaluations
Cons:
-loss of chronological order
-difficulty tracking trends
-fragments data bc of increased # of flow sheets required
, 4|Page
Focus charting - Answer--Directed at nursing diagnosis
-pt problem, concern, sign, symptom, or event
-three components (DAR)
D: data
A: Action
R: Response
advantages and disadvantages of focus charting - Answer-
pros:
-compatible w/ nursing process
-short document time w/ flow sheets
cons:
-pt problems may be missed
-doesnt adhere to charting w/ the focus on data analysis &
expected outcomes
Charting by exception - Answer--assumption that all
standards of practice are carried out & met w/ normal or
expected response unless otherwise documented
NURS 136 EXAM 3 NEWEST ACTUAL EXAM
COMPLETE QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||LATEST VERSION!!!
Purposes of documentation - Answer--written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
Medical record - Answer--Contains data about patient's
stay in a facility
-Only health care professionals directly caring for the
patient, or those involved in research or teaching, should
have access to the chart
-Patient information should not be discussed with anyone
not directly involved in the patient's care
Methods of documentation - Answer-1. Source-
oriented/narrative records
,2|Page
2. Problem-oriented medical records
3. Focus charting
4. Charting by exception
5. Case management model
6. Computerized documentation/Electronic health records
(EHRs)
Advantage and disadvantage of Source-Oriented MR/
Narrative - Answer-Pro:
-info of pt in chronological order
-pt condition noted each shift
-steps of nursing process
Con:
-normal & abnormal findings
-extensive documentation by staff
-lengthy entries
Source oriented / narrative charting - Answer--organized
according to source info
-separate forms for nurses/physicians/etc.
,3|Page
problem-oriented medical record (POMR) - Answer--
Focuses on pt status
-contains 5 basic parts:
1. database
2. problem list
3.the plan
4. the progress notes
5. discharge summary
-uses SOAP
Advantages & disadvantages of Problem-oriented MR -
Answer-pros:
-improves continuity of care & communication by keeping
data relevant
-easy auditing of pt MR for staff evaluations
Cons:
-loss of chronological order
-difficulty tracking trends
-fragments data bc of increased # of flow sheets required
, 4|Page
Focus charting - Answer--Directed at nursing diagnosis
-pt problem, concern, sign, symptom, or event
-three components (DAR)
D: data
A: Action
R: Response
advantages and disadvantages of focus charting - Answer-
pros:
-compatible w/ nursing process
-short document time w/ flow sheets
cons:
-pt problems may be missed
-doesnt adhere to charting w/ the focus on data analysis &
expected outcomes
Charting by exception - Answer--assumption that all
standards of practice are carried out & met w/ normal or
expected response unless otherwise documented
