NURS 231 Exam 3 Questions With Verified
Answers Graded A+ 2024/2025
- accurate, up to date information
- collaborative
- privacy
- improve productivity
- reducing cost
- research
Electronic Health Records
- "mistaken entry" date and initial
- "mistaken entry - wrong chart" and sign off
- delete part of the permanent record - type explanation into computer with date, time, and initials
and submit explanation in writing to manager
correcting errors
- paper format in which each health care group keeps data on its own separate form
- easy for each discipline to find and chart pertinent date
- difficult to track problem and progress
- progress notes are called narrative notes
- narrative notes address routine care, patient data, and patient problem identified in the care plan
Source oriented records
- paper document organized around patient's problem rather than around source of information.
- all health care professionals document on the same forms
- entire team works collaboratively on patient problems and contribute to care plan
- SOAP (subjective, objective, assessment, plan) - intervention, evaluation, response
- SOOOAAP (subjective, objective, opinion, options, advice, agreed plan, plan of care for intervention
and follow up)
Problem-Oriented Medical Record
- problem, interventions, evaluation
- does not develop a specific care plan, care plan incorporated into progress notes
- patient assessment documented each shift using fill-in-the blank assessment forms (flow sheet)
- saves time because there is no separate care plan
- disadvantage is there is no formal care plan; must read all progress notes to identify problems and
planned interventions before initiating care
PIE charting
medical record
SOAP method intended for
nursing origin
PIE method intended for
- bring focus of care back to the patient's concerns
- focus may be patients strength, problem, or need
- focus column includes: patient concern, behaviors, therapies and responses, change in condition,
significant events such as teaching, consultation, monitoring
, - narrative portion of focus charting uses DAR (data, action, response)
Focus charting
- shorthand method of documenting that only charts abnormal findings
Charting by exception
- emphasis on quality, cost-effective care delivered within a limited time frame
- clearly identifies outcomes that selected groups of patients are expected to achieve each day of care
- includes collaborative pathways (critical pathways) that specify the care plan linked to outcomes
along a timeline.
- occurrence charting when a patient fails to meet an expected outcome
Case Management Model
- avoid words such as good, average, normal
- verbal orders should be documented VO with date, time, and name and credentials of the health
care provider who gave the orders.
Documentation Guidelines
- upon admission, transfer to unit, and discharge
- when a procedure is performed
- upon receiving a patient postoperatively or postprocedural
- upon communicating with health care providers regarding critical patient information (abnormal lab
values)
- for any change in patient status
when should a new progress note be written
- nursing diagnoses, goals, expected outcomes, and nursing interventions
care plan
- documentation, lab and test values, results, orders, medications
patient care summary
- case management plan
- expected outcomes, list of interventions to be performed, sequence and timing of interventions
critical/collaborative pathways
- informs care givers on progress of a patient
- narrative notes, SOAP, PIE, focus, CBE, and case management model
progress notes
- also called variance report or occurrence report
- document unexpected events that result or could result or could result in harm of a patient or
person or damage property
- used for high-risk management and quality improvement and are not intended to be used for
disciplinary action against staff members
Incident Reports
Answers Graded A+ 2024/2025
- accurate, up to date information
- collaborative
- privacy
- improve productivity
- reducing cost
- research
Electronic Health Records
- "mistaken entry" date and initial
- "mistaken entry - wrong chart" and sign off
- delete part of the permanent record - type explanation into computer with date, time, and initials
and submit explanation in writing to manager
correcting errors
- paper format in which each health care group keeps data on its own separate form
- easy for each discipline to find and chart pertinent date
- difficult to track problem and progress
- progress notes are called narrative notes
- narrative notes address routine care, patient data, and patient problem identified in the care plan
Source oriented records
- paper document organized around patient's problem rather than around source of information.
- all health care professionals document on the same forms
- entire team works collaboratively on patient problems and contribute to care plan
- SOAP (subjective, objective, assessment, plan) - intervention, evaluation, response
- SOOOAAP (subjective, objective, opinion, options, advice, agreed plan, plan of care for intervention
and follow up)
Problem-Oriented Medical Record
- problem, interventions, evaluation
- does not develop a specific care plan, care plan incorporated into progress notes
- patient assessment documented each shift using fill-in-the blank assessment forms (flow sheet)
- saves time because there is no separate care plan
- disadvantage is there is no formal care plan; must read all progress notes to identify problems and
planned interventions before initiating care
PIE charting
medical record
SOAP method intended for
nursing origin
PIE method intended for
- bring focus of care back to the patient's concerns
- focus may be patients strength, problem, or need
- focus column includes: patient concern, behaviors, therapies and responses, change in condition,
significant events such as teaching, consultation, monitoring
, - narrative portion of focus charting uses DAR (data, action, response)
Focus charting
- shorthand method of documenting that only charts abnormal findings
Charting by exception
- emphasis on quality, cost-effective care delivered within a limited time frame
- clearly identifies outcomes that selected groups of patients are expected to achieve each day of care
- includes collaborative pathways (critical pathways) that specify the care plan linked to outcomes
along a timeline.
- occurrence charting when a patient fails to meet an expected outcome
Case Management Model
- avoid words such as good, average, normal
- verbal orders should be documented VO with date, time, and name and credentials of the health
care provider who gave the orders.
Documentation Guidelines
- upon admission, transfer to unit, and discharge
- when a procedure is performed
- upon receiving a patient postoperatively or postprocedural
- upon communicating with health care providers regarding critical patient information (abnormal lab
values)
- for any change in patient status
when should a new progress note be written
- nursing diagnoses, goals, expected outcomes, and nursing interventions
care plan
- documentation, lab and test values, results, orders, medications
patient care summary
- case management plan
- expected outcomes, list of interventions to be performed, sequence and timing of interventions
critical/collaborative pathways
- informs care givers on progress of a patient
- narrative notes, SOAP, PIE, focus, CBE, and case management model
progress notes
- also called variance report or occurrence report
- document unexpected events that result or could result or could result in harm of a patient or
person or damage property
- used for high-risk management and quality improvement and are not intended to be used for
disciplinary action against staff members
Incident Reports
