Page 1 of 49
EXAM 3: NU136 / NU 136 (LATEST
UPDATES STUDY BUNDLE WITH COMPLETE SOLUTIONS)
FUNDAMENTALS OF NURSING | QUESTIONS AND
VERIFIED ANSWERS | 100% CORRECT | GRADE A –
GALEN
Purposes of documentation .....ANSWER.....-written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
Medical record .....ANSWER.....-Contains data about patient's
stay in a facility
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-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 .....ANSWER.....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 .....ANSWER.....Pro:
-info of pt in chronological order
,Page 3 of 49
-pt condition noted each shift
-steps of nursing process
Con:
-normal & abnormal findings
-extensive documentation by staff
-lengthy entries
Source oriented / narrative charting .....ANSWER.....-organized
according to source info
-separate forms for nurses/physicians/etc.
problem-oriented medical record (POMR) .....ANSWER.....-
Focuses on pt status
-contains 5 basic parts:
1. database
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2. problem list
3.the plan
4. the progress notes
5. discharge summary
-uses SOAP
Advantages & disadvantages of Problem-oriented MR
.....ANSWER.....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
EXAM 3: NU136 / NU 136 (LATEST
UPDATES STUDY BUNDLE WITH COMPLETE SOLUTIONS)
FUNDAMENTALS OF NURSING | QUESTIONS AND
VERIFIED ANSWERS | 100% CORRECT | GRADE A –
GALEN
Purposes of documentation .....ANSWER.....-written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
Medical record .....ANSWER.....-Contains data about patient's
stay in a facility
,Page 2 of 49
-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 .....ANSWER.....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 .....ANSWER.....Pro:
-info of pt in chronological order
,Page 3 of 49
-pt condition noted each shift
-steps of nursing process
Con:
-normal & abnormal findings
-extensive documentation by staff
-lengthy entries
Source oriented / narrative charting .....ANSWER.....-organized
according to source info
-separate forms for nurses/physicians/etc.
problem-oriented medical record (POMR) .....ANSWER.....-
Focuses on pt status
-contains 5 basic parts:
1. database
, Page 4 of 49
2. problem list
3.the plan
4. the progress notes
5. discharge summary
-uses SOAP
Advantages & disadvantages of Problem-oriented MR
.....ANSWER.....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
