NURSE PROGRESS NOTES

Question 1

must be logical (on-time and
actual situation that happens), focused (the
patient care and in giving the nursing
management, and intervention) and
relevant to care and must represent each
phase in the nursing process

Answer 1

Nursing notes

Question 2

would serve as the
foundation and baseline in terms of the
data (objective and subjective data)

Answer 2

Assessment

Question 3

will eventually serve as the
evidence of our nursing care to our clients

Answer 3

Documentation

Question 4

we usually put everything that we give to
the patient in terms of the nursing
management and how we handle
actually our clients and patients in terms
of giving them medical needs

Answer 4

Nurses notes

Question 5

wherein we write and
take note or record all the medication of
the patien

Answer 5

Medication sheet

Question 6

wherein we
actually record and take the notes the
intravenous fluid infused to our clients
and what type of fluid is this

Answer 6

Intravenous sheet

Question 7

• Traditional method
• Chronologic account written in paragraphs ; very lengthy and specific

Answer 7

narrative charting

Question 8

• Problem-oriented medical record (POMR)
employs a structured, logical format.
• SOAP, SOAPIE, SOAPIER

Answer 8

problem oriented charting

Question 9

• Use of a column format to chart data,
action and response (DAR)
• Usually the focus is a nursing diagnosis, but
it may refer to:
→ A sign or symptom
→ Acute change in patient’s condition
→ A special need

Answer 9

focus charting

Question 10

Meaning of soapier

Answer 10

Subjective objective assessment plan intervention evaluation revision

Question 11

Meaning of FDAR

Answer 11

Focus data action response