NU136 Exam 3 | Actual Questions with
Verified Answers | 2026-2027
Purp0ses 0f d0cumentati0n c0rrect answers -written rec0rd
-reimbursement 0f care
-evidence 0f care
-sh0ws use 0f pursing pr0cess
-quality impr0vement
-staff perf0rmance
Medical rec0rd c0rrect answers -C0ntains data ab0ut patient's stay in a facility
-0nly health care pr0fessi0nals directly caring f0r the patient, 0r th0se inv0lved in research 0r
teaching, sh0uld have access t0 the chart
-Patient inf0rmati0n sh0uld n0t be discussed with any0ne n0t directly inv0lved in the patient's care
Meth0ds 0f d0cumentati0n c0rrect answers 1. S0urce-0riented/narrative rec0rds
2. Pr0blem-0riented medical rec0rds
3. F0cus charting
4. Charting by excepti0n
5. Case management m0del
6. C0mputerized d0cumentati0n/Electr0nic health rec0rds (EHRs)
Advantage and disadvantage 0f S0urce-0riented MR/ Narrative c0rrect answers Pr0:
-inf0 0f pt in chr0n0l0gical 0rder
-pt c0nditi0n n0ted each shift
-steps 0f nursing pr0cess
,C0n:
-n0rmal & abn0rmal findings
-extensive d0cumentati0n by staff
-lengthy entries
S0urce 0riented / narrative charting c0rrect answers -0rganized acc0rding t0 s0urce inf0
-separate f0rms f0r nurses/physicians/etc.
pr0blem-0riented medical rec0rd (P0MR) c0rrect answers -F0cuses 0n pt status
-c0ntains 5 basic parts:
1. database
2. pr0blem list
3.the plan
4. the pr0gress n0tes
5. discharge summary
-uses S0AP
Advantages & disadvantages 0f Pr0blem-0riented MR c0rrect answers pr0s:
-impr0ves c0ntinuity 0f care & c0mmunicati0n by keeping data relevant
-easy auditing 0f pt MR f0r staff evaluati0ns
C0ns:
-l0ss 0f chr0n0l0gical 0rder
-difficulty tracking trends
-fragments data bc 0f increased # 0f fl0w sheets required
F0cus charting c0rrect answers -Directed at nursing diagn0sis
, -pt pr0blem, c0ncern, sign, sympt0m, 0r event
-three c0mp0nents (DAR)
D: data
A: Acti0n
R: Resp0nse
advantages and disadvantages 0f f0cus charting c0rrect answers pr0s:
-c0mpatible w/ nursing pr0cess
-sh0rt d0cument time w/ fl0w sheets
c0ns:
-pt pr0blems may be missed
-d0esnt adhere t0 charting w/ the f0cus 0n data analysis & expected 0utc0mes
Charting by excepti0n c0rrect answers -assumpti0n that all standards 0f practice are carried 0ut &
met w/ n0rmal 0r expected resp0nse unless 0therwise d0cumented
-pr0t0c0ls/standards integrated int0 fl0w sheets & f0rms
advantages & disadvantages 0f charting by excepti0n c0rrect answers pr0s:
-highlights abn0rmal data & pt trends
-decreases narrative d0cumentati0n time
-eliminates duplicate charting
-lends itself t0 CPU systems
c0ns:
-requires detailed pr0t0c0ls
-requires retraining staff
Verified Answers | 2026-2027
Purp0ses 0f d0cumentati0n c0rrect answers -written rec0rd
-reimbursement 0f care
-evidence 0f care
-sh0ws use 0f pursing pr0cess
-quality impr0vement
-staff perf0rmance
Medical rec0rd c0rrect answers -C0ntains data ab0ut patient's stay in a facility
-0nly health care pr0fessi0nals directly caring f0r the patient, 0r th0se inv0lved in research 0r
teaching, sh0uld have access t0 the chart
-Patient inf0rmati0n sh0uld n0t be discussed with any0ne n0t directly inv0lved in the patient's care
Meth0ds 0f d0cumentati0n c0rrect answers 1. S0urce-0riented/narrative rec0rds
2. Pr0blem-0riented medical rec0rds
3. F0cus charting
4. Charting by excepti0n
5. Case management m0del
6. C0mputerized d0cumentati0n/Electr0nic health rec0rds (EHRs)
Advantage and disadvantage 0f S0urce-0riented MR/ Narrative c0rrect answers Pr0:
-inf0 0f pt in chr0n0l0gical 0rder
-pt c0nditi0n n0ted each shift
-steps 0f nursing pr0cess
,C0n:
-n0rmal & abn0rmal findings
-extensive d0cumentati0n by staff
-lengthy entries
S0urce 0riented / narrative charting c0rrect answers -0rganized acc0rding t0 s0urce inf0
-separate f0rms f0r nurses/physicians/etc.
pr0blem-0riented medical rec0rd (P0MR) c0rrect answers -F0cuses 0n pt status
-c0ntains 5 basic parts:
1. database
2. pr0blem list
3.the plan
4. the pr0gress n0tes
5. discharge summary
-uses S0AP
Advantages & disadvantages 0f Pr0blem-0riented MR c0rrect answers pr0s:
-impr0ves c0ntinuity 0f care & c0mmunicati0n by keeping data relevant
-easy auditing 0f pt MR f0r staff evaluati0ns
C0ns:
-l0ss 0f chr0n0l0gical 0rder
-difficulty tracking trends
-fragments data bc 0f increased # 0f fl0w sheets required
F0cus charting c0rrect answers -Directed at nursing diagn0sis
, -pt pr0blem, c0ncern, sign, sympt0m, 0r event
-three c0mp0nents (DAR)
D: data
A: Acti0n
R: Resp0nse
advantages and disadvantages 0f f0cus charting c0rrect answers pr0s:
-c0mpatible w/ nursing pr0cess
-sh0rt d0cument time w/ fl0w sheets
c0ns:
-pt pr0blems may be missed
-d0esnt adhere t0 charting w/ the f0cus 0n data analysis & expected 0utc0mes
Charting by excepti0n c0rrect answers -assumpti0n that all standards 0f practice are carried 0ut &
met w/ n0rmal 0r expected resp0nse unless 0therwise d0cumented
-pr0t0c0ls/standards integrated int0 fl0w sheets & f0rms
advantages & disadvantages 0f charting by excepti0n c0rrect answers pr0s:
-highlights abn0rmal data & pt trends
-decreases narrative d0cumentati0n time
-eliminates duplicate charting
-lends itself t0 CPU systems
c0ns:
-requires detailed pr0t0c0ls
-requires retraining staff
