NU 136 - EXAM 3 REVIEW | QUESTIONS AND ANSWERS
| RATED 100% CORRECT - GALEN SCHOOL OF NURSING.
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
-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
-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
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
-fragments data bc of increased # of flow sheets required
Focus charting Answer - -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 Answer - 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 Answer - -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 Answer - pros:
-highlights abnormal data & pt trends
-decreases narrative documentation time
| RATED 100% CORRECT - GALEN SCHOOL OF NURSING.
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
-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
-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
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
-fragments data bc of increased # of flow sheets required
Focus charting Answer - -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 Answer - 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 Answer - -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 Answer - pros:
-highlights abnormal data & pt trends
-decreases narrative documentation time
