Chapter 7 deWit's Fundamental
Concepts and Skills for Nursing Practice
Exam And 100% Accurate Answers.
case management charting - Answer Documentation that tracks variances from the clinical pathway
Charting - Answer Documentation of the nursing process, treatment, and associated care.
Charting by Exception - Answer Documentation that focuses on deviations from predefined norms,
using preset protocols and standards of care.
Computer-assisted charting - Answer Documentation in which data are input via the computer.
computerized provider order entry (CPOE) - Answer The entering of provider orders into the medical
record via computer.
electronic health record (EHR) - Answer Health record entered into a computer's software program that
is updated via the computer.
focus charting - Answer Documentation that centers on the patient from a positive perspective; this
form of documentation has three components: data, action, and response.
medical record - Answer Paper or electronic record that contains all orders, test, treatments, and care
that occurred during the time a person was under the care of a health care provider.
PIE charting - Answer Method of documentation in which "P" means problem identification, "I" means
interventions, and "E" means evaluation.
problem-oriented medical record (POMR) charting - Answer Documentation that focuses on patient
status, emphasizes the problem-solving approach to patient care, and provides a method for
communicating what, when, and how things are to be done to meet the patient's needs.
Concepts and Skills for Nursing Practice
Exam And 100% Accurate Answers.
case management charting - Answer Documentation that tracks variances from the clinical pathway
Charting - Answer Documentation of the nursing process, treatment, and associated care.
Charting by Exception - Answer Documentation that focuses on deviations from predefined norms,
using preset protocols and standards of care.
Computer-assisted charting - Answer Documentation in which data are input via the computer.
computerized provider order entry (CPOE) - Answer The entering of provider orders into the medical
record via computer.
electronic health record (EHR) - Answer Health record entered into a computer's software program that
is updated via the computer.
focus charting - Answer Documentation that centers on the patient from a positive perspective; this
form of documentation has three components: data, action, and response.
medical record - Answer Paper or electronic record that contains all orders, test, treatments, and care
that occurred during the time a person was under the care of a health care provider.
PIE charting - Answer Method of documentation in which "P" means problem identification, "I" means
interventions, and "E" means evaluation.
problem-oriented medical record (POMR) charting - Answer Documentation that focuses on patient
status, emphasizes the problem-solving approach to patient care, and provides a method for
communicating what, when, and how things are to be done to meet the patient's needs.
