NUR 155 Exam 1 Documentation (Ch. 15) Questions and Answers

NUR 155 Exam 1 Documentation (Ch. 15) Questions and Answers Source-Oriented Records - Answer ️️ -One in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc. Source-Oriented Records - Answer ️️ -Each discipline can easily find and chart pertinent data is an example of an advantage of what? Source-Oriented Records - Answer ️️ -Fragmented data -- making it difficult to track problems chronologically with input from different groups of professionals data is an example of a disadvantage of what? Narrative Charting - Answer ️️ -Consists of written notes that include routine care, normal findings, and client problems. Problem-Oriented Medical Records (POMR) - Answer ️️ -Data arranged according to client problem rather than the source of the information. SOAPIER Data - Answer ️️ -Subjective data, objective data, assessment, plan, interventions, evaluation, revision Subjective data - Answer ️️ -Information obtained from what the clients tells you. Objective Data - Answer ️️ -Information that is measured or observed by use of the senses. Assessment - Answer ️️ -An interpretation or inclusion drawn about the subjective and objective data. Plan - Answer ️️ -Preparation of the care designed to resolve the stated problem. Interventions - Answer ️️ -The specific care that has actually been performed by the caregiver