Documentation

Question 1

Source oriented medical record

Answer 1

• Each discipline has a separate section to record data
• advantages: easy to locate information
• disadvantage: information is fragmented

Question 2

Components of source oriented record

Answer 2

• admission fact sheet
• physicians order
• graphic sheet
• activity flow sheet
• meditation record
• medical history and exam
• progress sheet
• miscellaneous

Question 3

Problem oriented medical record (POMR)

Answer 3

• emphasis on patient problem
• organized by problem not source of information
• nurses may be only ones utilizing this format

Question 4

Components of POMR

Answer 4

• defined data base
• problem list
• care plans
• progress notes
• SOAP format

Question 5

SOAP charting

Answer 5

S- situation
O- objective data
A- assessment
P- plan

Question 6

Charting by exception

Answer 6

• how to see define criteria for data collected and interventions
• only exceptions to the norms or significant findings are charted in narrative format (only abnormal data!)
• flow sheets are used

Question 7

Transfer report (ISBARR)

Answer 7

I- identify/ introduce 
S- situation 
B- background
A- assessment 
R- recommendation 
R- read back of orders / response

Question 8

Change if shift in ISBARR

Answer 8

• name, room number, bed designation, diagnosis, attending and consulting physician of pt
• current appraisal of each patient
• current orders
• abnormal occurrences
• any infilled orders that need to be continued onto next shift
• patient/ family questions or concerns
• reports on transfer/ discharge

Question 9

Nurses notes

Answer 9

Objective
Clear 
Accurate
Descriptive 
Concise

Question 10

Malpractice litigation

Answer 10

• not charting the correct time
• failing the i record verbal orders or have them signed by MD
• charting in advance
• documentation of incorrect data

Question 11

Guidelines

Answer 11

• do not erase, scratch out With one line
• initial and follow with correction
• legible and written in black ink
• signature