NU 136 EXAM 3 REVIEW QUESTIONS AND ANSWERS
Purposes of documentation - CORRECT ANSWER✅✅-written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
Medical record - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER✅✅-organized according to source info
-separate forms for nurses/physicians/etc.
problem-oriented medical record (POMR) - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER✅✅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 - CORRECT ANSWER✅✅computerized record of pt history
advantages & disadvantages of computer assisted charting - CORRECT ANSWER✅✅pros:
-automatic date/time
-legible
Purposes of documentation - CORRECT ANSWER✅✅-written record
-reimbursement of care
-evidence of care
-shows use of pursing process
-quality improvement
-staff performance
Medical record - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER✅✅-organized according to source info
-separate forms for nurses/physicians/etc.
problem-oriented medical record (POMR) - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER✅✅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 - CORRECT ANSWER✅✅computerized record of pt history
advantages & disadvantages of computer assisted charting - CORRECT ANSWER✅✅pros:
-automatic date/time
-legible
