A measurable patient goal b progress toward goal c

a. Measurable patient goal
b. Progress toward goal
c. Need for referral
d. Discharge date
ANS: A, B
The information within a recorded entry must be complete, containing appropriate and
essential information. There are criteria for thorough communication for certain health
situations. For example, when recording discharge planning, measurable patient goals or
expected outcomes, progress toward goals, and need for referrals are always included.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment
TOP: Integrated Process: Communication and Documentation
4. In a POMR charting method of documentation, which of the following items are used?
( Select all that apply. )
a. Progress notes
b. Database
c. Medical diagnosis
d. Problem list
e. Care plan
ANS: A, B, D, E
The problem-oriented medical record (POMR) is a structured method of documentation that
emphasizes a patient’s problems. It is organized using the nursing process. Organization of
data is by problem or diagnosis. Ideally each member of the health care team contributes to a
single list of identified patient problems. Each recording includes a database, problem list,
care plan, and progress notes.
N
DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment
TOP: Integrated Process: Communication and Documentation

Chapter 04: Patient Safety and Quality Improvement
Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition
MULTIPLE CHOICE
1. The nurse is caring for an older patient who has a non–weight-bearing cast on the left lower
extremity. The patient ambulates without using a walker despite repeated instruction from the
nurse to call for assistance. Which response by the nurse is most likely to keep the patient
from falling?