Exam 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?

Regarding access to client records,the nursing faculty informs the nursing students to be prepared to:

When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider,this is called a:

Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?

The nurse makes a late entry in a client's record.Which of the following is the best example of how to document this type of situation?

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

The following statement: "Upon exertion,the client is wheezing and experiencing some dyspnea," is an example of:

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

To locate the recording of a nurse's description of the teaching provided to the client on performance of self-medication administration,one would look in a(n):