chapter 7 verified questions and solutions A+ grade
What are the six main methods of documentation (charting)? - - Source-oriented
(narrative), problem-oriented (POMR), focus charting, charting by exception, computer-assisted
charting, and case management system charting
What are the five basic parts of a POMR (problem-oriented medical record)? - -
Database, problem list, plan, progress notes, and discharge summary
In PIE charting, what does P-I-E stand for? - - Problem identification, Intervention, and
Evaluation
In focus (DAR) charting, what does D-A-R stand for? - - Data, Action, and Response
What charting method assumes all standards of care are met unless otherwise noted, writing a
note only for abnormal findings? - - Charting by exception
What is a disadvantage of source-oriented/narrative charting? - - It requires extensive
charting time and makes it hard to separate pertinent from irrelevant information
What electronic system provides a computerized record of a patient's history and care across all
facilities and admissions? - - Electronic health record (EHR)
What computer system automatically routes physician orders to the appropriate clinical
department? - - Computerized provider order entry (CPOE)
What three qualities should nursing documentation always have? - - Accurate, brief, and
complete
What are the six main methods of documentation (charting)? - - Source-oriented
(narrative), problem-oriented (POMR), focus charting, charting by exception, computer-assisted
charting, and case management system charting
What are the five basic parts of a POMR (problem-oriented medical record)? - -
Database, problem list, plan, progress notes, and discharge summary
In PIE charting, what does P-I-E stand for? - - Problem identification, Intervention, and
Evaluation
In focus (DAR) charting, what does D-A-R stand for? - - Data, Action, and Response
What charting method assumes all standards of care are met unless otherwise noted, writing a
note only for abnormal findings? - - Charting by exception
What is a disadvantage of source-oriented/narrative charting? - - It requires extensive
charting time and makes it hard to separate pertinent from irrelevant information
What electronic system provides a computerized record of a patient's history and care across all
facilities and admissions? - - Electronic health record (EHR)
What computer system automatically routes physician orders to the appropriate clinical
department? - - Computerized provider order entry (CPOE)
What three qualities should nursing documentation always have? - - Accurate, brief, and
complete
