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Documentation System

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Total Questions : 5

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Question 1:

A nurse is reviewing the documentation system of a client’s chart.

Which of the following is an advantage of using a source-oriented record?

A. It encourages collaboration among health care providers. B. It organizes the data according to the client’s problems. C. It tracks the status of each problem using a problem list. D. It keeps data from each person or department in a separate section.

Answer and Explanation

Choice A:

It does not encourage collaboration among health care providers.In fact, a source-oriented record may hinder communication and coordination of care because the data are fragmented and scattered throughout the chart.

Choice B:

It does not organize the data according to the client’s problems.A problem-oriented medical record (POMR) is a different type of documentation system that arranges the data based on the problems identified by the health care team.The POMR has four components: database, problem list, plan of care, and progress notes.

Choice C:

It does not track the status of each problem using a problem list.This is also a feature of the POMR, not the source-oriented record.A problem list is a numbered list of the client’s current and resolved problems that serves as an index to the progress notes.

Choice D:

It keeps data from each person or department in a separate section.A source-oriented record is a type of documentation system that organizes the data according to the source of information, such as the physician, nurse, laboratory, or physical therapy.This format has the advantage of making it easy to locate and trace the information from each person or department who provided care to the client.

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Question 2:

A nurse is preparing to document the care plan for a client who has a problem-oriented medical record (POMR).

Which of the following actions should the nurse take?

(Select all that apply.).

A. Generate the care plan from the database. B. Number the care plan to correspond to the problem list. C. Repeat assessments and interventions that apply to more than one problem. D. Update the problem list as needed. E. Use a standardized format for chart entries.

Answer and Explanation

Choice A:

The nurse should not generate the care plan from the database, but rather from the problem list.The problem list is the centerpiece of the POMR and reflects the patient’s current health status and needs.

Choice B:

The nurse shouldnumber the care plan to correspond to the problem listandupdate the problem list as needed.These actions are consistent with the principles of the problem-oriented medical record (POMR), which is a method of organizing patient information by the health problems that require attention.The POMR includes a patient database, a problem list, a plan of care, and progress notes.

Choice C:

The nurse should not repeat assessments and interventions that apply to more than one problem, but rather use cross-referencing to avoid duplication and confusion.

Choice D:

Choice E:

The nurse should not use a standardized format for chart entries, but rather use a SOAP format (subjective, objective, assessment, plan) or a modified version of it (such as SOAPIE or SOAPIER) to document each problem and its progress.

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Question 3:

A nurse is using the SOAP format to write a progress note for a client who has impaired physical mobility.

Which of the following statements should the nurse include as the subjective data?

A. “The client walked 10 feet with a walker today.”. B. “The client reports feeling less pain in his left leg.”. C. “The client has decreased range of motion in his right shoulder.”. D. “The client needs assistance with bathing and dressing.”.

Answer and Explanation

Choice A:

It is objective data, which is measurable and observable by the nurse or other healthcare providers.Objective data is what the nurse sees, hears, feels, or smells.

Choice B:

This is the subjective data because it is based on the client’s own perception and feelings.Subjective data is what the client tells the nurse or what the nurse observes from the client’s behavior.

Choice C:

It is also objective data, as it can be measured by the nurse using a goniometer or other tools.

Choice D:

It is also objective data, as it can be observed by the nurse or documented in the care plan.

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Question 4:

A nurse is using the PIE format to write a progress note for a client who has constipation.

Which of the following statements should the nurse include as the intervention?

A. “Encouraged the client to increase fluid and fiber intake.”. B. “Assessed the client’s bowel sounds and abdominal distension.”. C. “Administered bisacodyl suppository as prescribed.”. D. “Evaluated the client’s response to the suppository.”.

Answer and Explanation

Choice A:

It is not an intervention, but a health promotion activity.

Encouraging the client to increase fluid and fiber intake is a good practice, but it is not directly related to the problem of constipation.

Choice B:

It is not an intervention, but an assessment.

Assessing the client’s bowel sounds and abdominal distension is part of the data collection process, but it does not solve the problem of constipation.

Choice C:

The PIE format is a method of documentation that states theproblemor diagnosis (P), theinterventionor action the nurse takes (I), and theevaluationof the results (E).It eliminates the need for a traditional care plan by incorporating it into the progress notes.

The intervention is the action that the nurse takes to address the problem.

In this case, the problem is constipation, and the intervention is administering a bisacodyl suppository as prescribed by the physician.

This is a specific and measurable action that can be evaluated later.

Choice D:

It is not an intervention, but an evaluation.

Evaluating the client’s response to the suppository is the last step of the PIE format, where the nurse determines if the intervention was effective or not.

It does not describe what the nurse did to address the problem of constipation.

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Question 5:

A nurse is using the DAR format to write a progress note for a client who has a history of hypertension.

Which of the following statements should the nurse include as the action?

A. “Blood pressure was 150/90 mm Hg at 0800.”. B. “Instructed the client on low-sodium diet and exercise.”. C. “Goal met: Blood pressure decreased to 130/80 mm Hg at 1200.”. D. “Risk for injury related to elevated blood pressure.”.

Answer and Explanation

Choice A:

It is not an action, but a data.

Data is the information that the nurse collected about the client’s condition, such as vital signs, symptoms, or test results.

Data should be factual and objective.

Choice B:

This is the action that the nurse took to address the client’s problem of hypertension.

The action should describe the nursing intervention that was performed to help the client achieve the expected outcome.

Choice C:

It is not an action, but a response.

Response is the outcome or result of the nursing intervention, such as the client’s reaction, behavior, or change in condition.

Response should be measurable and evaluative.

Choice D:

It is not an action, but a focus.

Focus is the reason or purpose for writing the note, such as a nursing diagnosis, a change in condition, or a patient education need.

Focus should be concise and specific.

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Documentation System

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