Fundamentals Exam 3 Study Guide
Unit 7
DOCUMENTATION OF NURSING CARE
I. PURPOSES OF DOCUMENTATION
Documentation is more than writing notes—it is a legal, professional, and
clinical tool.
Example /
Purpose Function / Role Clinical Memory Tip
Location
Nursing notes, “If it’s not
Legal proof of care
Written record medication documented, it
delivered
administration wasn’t done”
Proper charting →
Supports insurance Hospital billing,
Reimbursement correct
claims, billing insurance audits
reimbursement
Provides proof for legal or Lawsuits, Keep facts factual,
Evidence of care
professional review malpractice avoid opinions
Demonstrates assessment
NCLEX loves
Shows use of → planning → Nursing care plan
seeing NP steps
nursing process implementation → notes
documented
evaluation
, Complete
Quality Tracks outcomes, safety Fall audits,
documentation =
improvement events infection control
better QI
Chart reviews, Accurate notes =
Research Data for studies and EBP
nursing research usable data
Peer review, Use measurable
Staff Evaluates interventions
performance outcomes, not
performance and outcomes
appraisal vague terms
NCLEX Golden Rule:
• Documentation = legal, professional, and clinical protection.
II. THE MEDICAL RECORD
Definition:
• Contains all data about a patient’s stay in a facility.
Legal & Ethical Considerations:
• Privacy & Confidentiality: HIPAA
• Who can access:
o Assigned healthcare providers
o Patient (sometimes via request)
o Insurance/legal entities as required
NCLEX Insight:
• Unauthorized access → breach of confidentiality → legal
consequences
Clinical Location:
, • Hospital, clinic, home health, long-term care
III. METHODS OF DOCUMENTATION
1️⃣ Source-Oriented (Narrative) Charting
Definition: Organized by source of information (e.g., nurse, physician,
therapist).
Features:
• Separate forms per provider
• Chronological narrative notes
• Example: “Patient reports pain 7/10. Administered acetaminophen.
Pain 4/10 in 30 min.”
Advantages:
• Easy to find notes by provider
• Full story of care
Disadvantages:
• Requires reading multiple forms
• Hard to track problem trends
NCLEX Tip:
• Chronological order = legal timeline
2️⃣ Problem-Oriented Medical Record (POMR)
Definition: Focuses on patient problems, not who provided care.
, Five Parts:
1. Database → history, physical, labs
2. Problem list → prioritized problems
3. Plan → interventions
4. Progress notes → updates
5. Discharge summary → outcomes
Documentation Formats Used in POMR:
• SOAP/IE
Letter Meaning NCLEX Focus
S Subjective data Patient quotes, complaints
O Objective data Vital signs, lab values, observations
A Assessment Nurse analysis, diagnosis
P Plan Interventions to address problem
I Implementation Nursing actions taken
E Evaluation Outcome of interventions
Advantages:
• Focused on patient problems
• Easy to audit interventions
Disadvantages:
• May omit narrative context
• Time-consuming
Unit 7
DOCUMENTATION OF NURSING CARE
I. PURPOSES OF DOCUMENTATION
Documentation is more than writing notes—it is a legal, professional, and
clinical tool.
Example /
Purpose Function / Role Clinical Memory Tip
Location
Nursing notes, “If it’s not
Legal proof of care
Written record medication documented, it
delivered
administration wasn’t done”
Proper charting →
Supports insurance Hospital billing,
Reimbursement correct
claims, billing insurance audits
reimbursement
Provides proof for legal or Lawsuits, Keep facts factual,
Evidence of care
professional review malpractice avoid opinions
Demonstrates assessment
NCLEX loves
Shows use of → planning → Nursing care plan
seeing NP steps
nursing process implementation → notes
documented
evaluation
, Complete
Quality Tracks outcomes, safety Fall audits,
documentation =
improvement events infection control
better QI
Chart reviews, Accurate notes =
Research Data for studies and EBP
nursing research usable data
Peer review, Use measurable
Staff Evaluates interventions
performance outcomes, not
performance and outcomes
appraisal vague terms
NCLEX Golden Rule:
• Documentation = legal, professional, and clinical protection.
II. THE MEDICAL RECORD
Definition:
• Contains all data about a patient’s stay in a facility.
Legal & Ethical Considerations:
• Privacy & Confidentiality: HIPAA
• Who can access:
o Assigned healthcare providers
o Patient (sometimes via request)
o Insurance/legal entities as required
NCLEX Insight:
• Unauthorized access → breach of confidentiality → legal
consequences
Clinical Location:
, • Hospital, clinic, home health, long-term care
III. METHODS OF DOCUMENTATION
1️⃣ Source-Oriented (Narrative) Charting
Definition: Organized by source of information (e.g., nurse, physician,
therapist).
Features:
• Separate forms per provider
• Chronological narrative notes
• Example: “Patient reports pain 7/10. Administered acetaminophen.
Pain 4/10 in 30 min.”
Advantages:
• Easy to find notes by provider
• Full story of care
Disadvantages:
• Requires reading multiple forms
• Hard to track problem trends
NCLEX Tip:
• Chronological order = legal timeline
2️⃣ Problem-Oriented Medical Record (POMR)
Definition: Focuses on patient problems, not who provided care.
, Five Parts:
1. Database → history, physical, labs
2. Problem list → prioritized problems
3. Plan → interventions
4. Progress notes → updates
5. Discharge summary → outcomes
Documentation Formats Used in POMR:
• SOAP/IE
Letter Meaning NCLEX Focus
S Subjective data Patient quotes, complaints
O Objective data Vital signs, lab values, observations
A Assessment Nurse analysis, diagnosis
P Plan Interventions to address problem
I Implementation Nursing actions taken
E Evaluation Outcome of interventions
Advantages:
• Focused on patient problems
• Easy to audit interventions
Disadvantages:
• May omit narrative context
• Time-consuming
