In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents "Subjective: denies itching. Happy with improvement in skin.
Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge.” This type of documentation is an example of:
A) charting by exception.
B) narrative style.
C) a problem-oriented medical record (POMR).
D) the case management system.

Question

Quizplus · Accepted Answer

The POMR focuses on a patient problem or nursing diagnosis and typically uses the SOAP (subjective, objective, assessment, plan) format as shown here.

In a Medical Record for a Patient Who Has Had