NU 136 Fundamentals Exam 3 (2026/2027) |
Latest Exam Questions | Revision Pack | A+
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• Purposes of documentation -✓✓-written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
• Medical record -✓✓-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 -✓✓1. Source-oriented/narrative records
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 -✓✓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 -✓✓-organized according to source info
-separate forms for nurses/physicians/etc.
• problem-oriented medical record (POMR) -✓✓-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 -✓✓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
• Focus charting -✓✓-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 -✓✓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 -✓✓-assumption that all standards of practice are carried
out & met w/ normal or expected response unless otherwise documented
-protocols/standards integrated into flow sheets & forms
Latest Exam Questions | Revision Pack | A+
Verified
• Purposes of documentation -✓✓-written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
• Medical record -✓✓-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 -✓✓1. Source-oriented/narrative records
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 -✓✓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 -✓✓-organized according to source info
-separate forms for nurses/physicians/etc.
• problem-oriented medical record (POMR) -✓✓-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 -✓✓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
• Focus charting -✓✓-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 -✓✓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 -✓✓-assumption that all standards of practice are carried
out & met w/ normal or expected response unless otherwise documented
-protocols/standards integrated into flow sheets & forms
