NU 136 - Exam 3 Questions and answers
2025
Purposes .of .documentation .- .ANS✓✓--written .record .
-reimbursement .of .care
-evidence .of .care
-shows .use .of .pursing .process
-quality .improvement .
-staff .performance
Medical .record .- .ANS✓✓--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 .- .ANS✓✓-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 .- .ANS✓✓-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 .- .ANS✓✓--organized .according .to .source
.info
-separate .forms .for .nurses/physicians/etc.
problem-oriented .medical .record .(POMR) .- .ANS✓✓--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 .- .ANS✓✓-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 .- .ANS✓✓--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 .- .ANS✓✓-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 .- .ANS✓✓--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
advantages .& .disadvantages .of .charting .by .exception .- .ANS✓✓-pros: .
-highlights .abnormal .data .& .pt .trends
-decreases .narrative .documentation .time
-eliminates .duplicate .charting
-lends .itself .to .CPU .systems .
cons:
-requires .detailed .protocols
-requires .retraining .staff
-used .to .not .charting .important .data
Computer .assisted .charting .- .ANS✓✓-computerized .record .of .pt .history
advantages .& .disadvantages .of .computer .assisted .charting .- .ANS✓✓-pros:
, -automatic .date/time
-legible
-accessible .to .HCP
-decreased .documenting .time
cons: .
-risk .of .unauthorized .personnel .
-risk .of .computers .shutting .down
Case .management .system .charting .- .ANS✓✓--a .method .of .organizing .patient
.care .through .an .episode .of .illness .so .clinical .outcomes .are .achieved .within .an
.expected .time .frame .and .at .a .predictable .cost
-a .clinical .pathway .or .interdisciplinary .care .plan .takes .the .place .of .the .nursing
.care .plan
Factors .affecting .communication .- .ANS✓✓--culture
-past .trauma .
-mood .
-attitude
past .experiences: .- .ANS✓✓-cultural .values, .education, .familiarity .with
.occupation
emotions, .mood .& .environment: .- .ANS✓✓-Can .drastically .affect .the .way
.messages .are .sent .or .interpreted
attitude, .perceptions, .and .self .concept: .- .ANS✓✓-affects .both .how .message .is
.worded .and .the .body .language .that .accompanies .it.
Obtaining .feedback .- .ANS✓✓--A .vital .part .of .communication .is .checking .to .see
.if .you .interpreted .a .message .in .the .way .the .speaker .meant .it
-Accomplished .by .rephrasing .the .meaning .of .the .message .or .directly .asking .a
.feedback .question.
therapeutic .communication .techniques .- .ANS✓✓--using .silence
-asking .open .ended .questions
-restating
-clarifying
-using .touch
-using .general .leads
-offering .of .self
-encouraging .elaboration
-providing .pt .education
-looking .at .alternatives
-summarizing
communicating .with .hearing .impaired .pt: .- .ANS✓✓--maintain .distance .of .2 .1/2
.- .4 .feet .
2025
Purposes .of .documentation .- .ANS✓✓--written .record .
-reimbursement .of .care
-evidence .of .care
-shows .use .of .pursing .process
-quality .improvement .
-staff .performance
Medical .record .- .ANS✓✓--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 .- .ANS✓✓-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 .- .ANS✓✓-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 .- .ANS✓✓--organized .according .to .source
.info
-separate .forms .for .nurses/physicians/etc.
problem-oriented .medical .record .(POMR) .- .ANS✓✓--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 .- .ANS✓✓-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 .- .ANS✓✓--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 .- .ANS✓✓-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 .- .ANS✓✓--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
advantages .& .disadvantages .of .charting .by .exception .- .ANS✓✓-pros: .
-highlights .abnormal .data .& .pt .trends
-decreases .narrative .documentation .time
-eliminates .duplicate .charting
-lends .itself .to .CPU .systems .
cons:
-requires .detailed .protocols
-requires .retraining .staff
-used .to .not .charting .important .data
Computer .assisted .charting .- .ANS✓✓-computerized .record .of .pt .history
advantages .& .disadvantages .of .computer .assisted .charting .- .ANS✓✓-pros:
, -automatic .date/time
-legible
-accessible .to .HCP
-decreased .documenting .time
cons: .
-risk .of .unauthorized .personnel .
-risk .of .computers .shutting .down
Case .management .system .charting .- .ANS✓✓--a .method .of .organizing .patient
.care .through .an .episode .of .illness .so .clinical .outcomes .are .achieved .within .an
.expected .time .frame .and .at .a .predictable .cost
-a .clinical .pathway .or .interdisciplinary .care .plan .takes .the .place .of .the .nursing
.care .plan
Factors .affecting .communication .- .ANS✓✓--culture
-past .trauma .
-mood .
-attitude
past .experiences: .- .ANS✓✓-cultural .values, .education, .familiarity .with
.occupation
emotions, .mood .& .environment: .- .ANS✓✓-Can .drastically .affect .the .way
.messages .are .sent .or .interpreted
attitude, .perceptions, .and .self .concept: .- .ANS✓✓-affects .both .how .message .is
.worded .and .the .body .language .that .accompanies .it.
Obtaining .feedback .- .ANS✓✓--A .vital .part .of .communication .is .checking .to .see
.if .you .interpreted .a .message .in .the .way .the .speaker .meant .it
-Accomplished .by .rephrasing .the .meaning .of .the .message .or .directly .asking .a
.feedback .question.
therapeutic .communication .techniques .- .ANS✓✓--using .silence
-asking .open .ended .questions
-restating
-clarifying
-using .touch
-using .general .leads
-offering .of .self
-encouraging .elaboration
-providing .pt .education
-looking .at .alternatives
-summarizing
communicating .with .hearing .impaired .pt: .- .ANS✓✓--maintain .distance .of .2 .1/2
.- .4 .feet .
