Documentation of Nursing Care. Quizzes
and Verified Answers. Grade A.
Although charting by exception highlights abnormal data and patient trends, it presents
problems if called into court because only abnormal findings are documented in writing.
- ANS...
An advantage of focus charting is that it shortens charting time by using many flow
sheets and checklists. - ANS...
An advantage of the POMR system is that it improves continuity of care by keeping data
relevant to a problem all in one place. - ANS...
An advantage of the source-oriented method is that information on the patient's
condition and care is listed in chronological order. - ANS...
Besides nurses' and physicians' progress notes, many flow sheets are used to
document patient information. - ANS...
case management system charting - ANSa method of organizing patient care through
an episode of illness so that clinical outcomes are achieved within an expected time
frame and at a predictable cost
Case management system charting tracks variances from the care map. - ANS...
Chart the patient's behavior and statements, not your opinions or conclusions. - ANS...
charting - ANSused to track the application of the nursing process
charting by exception - ANSbased on the assumption that all standards of practice are
carried out and met with a normal or expected response unless otherwise documented;
a longhand note is written only when the standardized statement on the form is not met
Charting must be objective, accurate, brief, and complete. - ANS...
Computer charting is expensive to institute but saves considerable nursing time. -
ANS...
computer-assisted charting - ANSdata are input to the computer
computerized provider order entry (CPOE) - ANSprovides for efficient work flow
because when orders are entered into the computer, they are automatically routed to
the appropriate clinical areas for action
