Nurs1000 – Documentation Exam Study Guide with Complete Solutions
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Course
2024/2025
Institution
2024/2025
Nurs1000 – Documentation Exam Study
Guide with Complete Solutions
Standards of practice for nursing documentation - Answer-must be accurate, comprehensive, and
flexible enough for members of the health care team to retrieve critical data, maintain continuity of care
and track patient outcomes...
critical pathways or care maps - Answer✔✔-multidisciplinary care plans that include patient health
concerns, key interventions, and expected outcomes within an established time frame
source records - Answer✔✔-the patients chart is organized so that each discipline has a separate section
in which to record data
narrative documentation - Answer✔✔-the use of story-like format to document information specific to
patient conditions and nursing care
problem orientated medical records - Answer✔✔-a method of documentation that emphasizes the
patients problems
Data are organized by problem or diagnosis
SOAP - Answer✔✔-Subjective data
Objective data
Assessment
Plan
SOAPIE - Answer✔✔-Subjective data
Objective data
Assessment
Plan
Intervention
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