NU-136 Exam 3 Review Questions with Verified
Correct Answers
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
Correct Answers
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
