Author Question: Which of the following methods of documenting client data is least likely to hold up in court if a ... (Read 29 times)

chandani · **on:** Jul 23, 2018

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

A) Problem-oriented medical record
B) Charting by exception
C) PIE charting system
D) Focus charting

Question 2

Which one of the following methods of documentation is organized around client diagnoses rather than around patient information?

A) Problem-oriented medical record (POMR)
B) Source-oriented record
C) PIE charting system
D) focus charting

EAN94 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: B

Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or exceptions to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

Answer to Question 2

Ans: A

The POMR is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.