A nurse is reviewing with another nurse a method of documentation that includes data, action, and response (DAR) when charting client care. Which of the following methods of documentation is the nurse referring to?

Focus charting

Problem-oriented medical record (POMR)

SOAP documentation

PIE model

Answer and Explanation

The Correct Answer is A

A. Focus charting. Focus charting uses the DAR (Data, Action, Response) format to document client care. It emphasizes patient-centered concerns, such as symptoms, behaviors, or nursing diagnoses. This method allows for structured yet flexible documentation of important observations and interventions.

B. Problem-oriented medical record (POMR). POMR organizes documentation around specific health problems, using components like the database, problem list, care plan, and progress notes. It does not specifically follow the DAR format.

C. SOAP documentation. SOAP stands for Subjective, Objective, Assessment, and Plan and is used for problem-focused documentation. It differs from DAR, as it emphasizes a structured approach to analyzing and addressing patient problems.

D. PIE model. The PIE model (Problem, Intervention, Evaluation) focuses on nursing diagnoses and interventions rather than the DAR method of focus charting. It provides a problem-oriented approach but does not use the same structure as DAR documentation.

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Correct Answer is A

Explanation

A. Demographic data. An electronic health record (EHR) includes demographic information such as the client’s name, date of birth, contact details, and medical history. This data helps healthcare providers personalize care and ensure accurate record-keeping.

B. Billing payments. While healthcare facilities may have electronic billing systems, financial transactions and payments are not considered a core component of the EHR, which primarily focuses on clinical documentation and patient care.

C. Driver's license. A driver's license may be used for identity verification during registration, but it is not a required component of an EHR. Identifying information is documented separately from clinical records.

D. Facility policies. EHRs store patient-related health information rather than institutional policies. Facility policies are typically maintained in administrative systems or policy manuals, separate from patient medical records.

A. Fairness B. Confidence C. Responsibility D. Advocacy

Correct Answer is C

Explanation

A. Fairness. Fairness involves providing equitable and unbiased care to all patients. While fairness is a crucial aspect of nursing ethics, checking a client’s response to pain medication is more aligned with the nurse’s duty to follow through on patient care responsibilities.

B. Confidence. Confidence refers to a nurse’s self-assurance in their clinical skills and decision-making. Although confidence is important in nursing practice, evaluating a medication’s effectiveness is more about fulfilling a professional duty rather than demonstrating confidence.

C. Responsibility. Responsibility involves following through on nursing interventions and ensuring patient safety. By checking on the client to evaluate the effectiveness of a pain medication, the nurse is demonstrating accountability for patient care and adherence to proper nursing practice.

D. Advocacy. Advocacy involves speaking up for a patient’s rights, ensuring they receive appropriate care, and supporting their well-being. While assessing pain relief can contribute to advocacy, in this case, the nurse is primarily fulfilling their professional responsibility in medication administration and follow-up.

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A nurse is reviewing with another nurse a method of documentation that includes data, action, and response (DAR) when charting client care. Which of the following methods of documentation is the nurse referring to?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is providing an in-service on documentation with a group of staff nurses. Which of the following should the nurse include as a component of an electronic health record?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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