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