Chapter 7

Question 1

Patient data, including the demographics, next of kin, hospital identification number, religious preference, ins. info., health care provider, admitting dx

Answer 1

Face Sheet

Question 2

Record of serial measurements and observations, such as temperature, pulse, respiration, blood pressure, and weight

Answer 2

Graphic Sheet

Question 3

Care plan for the patient, including nursing dx, goals, and expected outcomes, and nursing interventions

Answer 3

Nursing Care Plan

Question 4

Documentation of the nursing process (ADPIE) a record of interventions implemented and the patient’s response to them

Answer 4

Nursing Notes

Question 5

Documentation of all medications ordered, doses given, and doses not taken by the patient

Answer 5

Medication Admin. Record (MAR)

Question 6

Organized by the “source” or author of the documentation entry

Answer 6

Source-orientated charting

Question 7

Focuses on the problems the patient experiences as a result of being ill

Answer 7

Problem oriented medical record charting (POMR)

Question 8

Focuses on the deviations from the predefined norms, using preset protocols and standards of care

Answer 8

Charting by Exception

Question 9

Tracks variances from the clinical pathway. Ex: Leg has sharp stinging pains when patient was admitted for pneumonia

Answer 9

Case Management System Charting