NU136 ASSESSMENT 3 FUNDAMENTALS OF
NURSING PREPARATION SCRIPT 2026
COMPREHENSIVE Q&A ALREADY PASSED
◉ 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
-eliminates duplicate charting
-lends itself to CPU systems
cons:
-requires detailed protocols
-requires retraining staff
-used to not charting important data
◉ Computer assisted charting Answer: computerized record of pt history
◉ advantages & disadvantages of computer assisted charting Answer:
pros:
-automatic date/time
-legible
-accessible to HCP
-decreased documenting time
cons:
NURSING PREPARATION SCRIPT 2026
COMPREHENSIVE Q&A ALREADY PASSED
◉ 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
-eliminates duplicate charting
-lends itself to CPU systems
cons:
-requires detailed protocols
-requires retraining staff
-used to not charting important data
◉ Computer assisted charting Answer: computerized record of pt history
◉ advantages & disadvantages of computer assisted charting Answer:
pros:
-automatic date/time
-legible
-accessible to HCP
-decreased documenting time
cons:
