Related to Problem Oriented Medical Record (POMR) documentation, ...

[Sportsfan2111]

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?
 
  1. His surgery corrected the mobility problem, so I drew a line through it and dated it.
  2. The client's problem list has several resolved problems on it; should I take them off?
  3. The client no longer has anxiety issues so I highlighted that problem on his prob-lem list.
  4. He doesn't experience any dizziness now that we have his medication regulated, so I've erased that from his problem list.

Question 2

The nurse realizes that the incorrect spelling of terms in the medical record most importantly:
 
  1. Shows a lack of competency
  2. Displays little attention to detail
  3. Contributes to serious treatment errors
  4. Negatively affects the accuracy of the documentation

[adammoses97]

Answer to Question 1

ANS: 4
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 ac-ceptable method of showing that a problem has been resolved.

Answer to Question 2

ANS: 3
Spelling errors can result in serious treatment errors; for example, the names of certain medica-tions 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.

[Sportsfan2111]

Excellent

[raenoj]

TYSM