Question 1

Related to Problem Oriented Medical Record (POMR)documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Accepted Answer

New problems are added as they are identified.When a problem has been resolved,record the date and highlight it or draw a line through the problem and its number.Erasure is not an acceptable method of showing that a problem has been resolved.

Question 2

The nurse realizes that the incorrect spelling of terms in the medical record most importantly:

Accepted Answer

Spelling errors can result in serious treatment errors;for example,the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar.Misspelling such terms can result in medication errors that may cause serious harm to a client.The other options are correct but do not have the seriousness of client care errors.

Question 3

The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:

Accepted Answer

A nursing student enters full name,student nurse abbreviation (e.g. ,SN or NS),and educational institution,such as "David Jones,SN (student nurse),CMTC (Central Maine Technical College)."

Question 4

Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

Accepted Answer

Common charting mistakes that can result in malpractice include the following: (1)failing to record pertinent health or drug information; (2)failing to record nursing actions; (3)failing to record that medications have been given; (4)failing to record drug reactions or changes in client's condition; (5)writing illegible or incomplete records;and (6)failing to document a discontinued medication.Detailed descriptions of procedures are not included in the nursing notes.

Question 5

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem.The evaluation is the client's objective or subjective response to the nursing intervention.

Question 6

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem.The evaluation is the client's objective or subjective response to the nursing intervention.

Question 7

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem.The evaluation is the client's objective or subjective response to the nursing intervention.

Question 8

Related to Problem Oriented Medical Record (POMR)documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Accepted Answer

New problems are added as they are identified.When a problem has been resolved,record the date and highlight it or draw a line through the problem and its number.Erasure is not an acceptable method of showing that a problem has been resolved.

Question 9

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem.The evaluation is the client's objective or subjective response to the nursing intervention.

Quiz 26: Documentation and Informatics

Related to Problem Oriented Medical Record (POMR) documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

The nurse realizes that the incorrect spelling of terms in the medical record most importantly:

The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a client's medical record is:

Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Related to Problem Oriented Medical Record (POMR) documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Which of the following is an example of an intervention used in the Problem-Intervention-Evaluation documentation method?