Which entry in the medical record will meet the requirement that the nurse must document with
problem-oriented charting?
a. "A: Client muttering to self as though answering an unseen person. P: Sensory
perceptual alteration related to internal auditory stimulation. I: Client received prn
fluphenazine po at 9 AM and went to room to lie down. E: Client calmer by 9:30
AM. Returned to community room to watch TV.".
b. "Agitated behavior. D: Client muttering to self as though answering an unseen
person. A: Given Haldol 2 mg po and went to room to lie down. E: Client calmer.
Returned to lounge to watch TV.".
c. "S: Client states ‘I feel like I'm ready to blow up.' O: Pacing hall and mumbling
to self as though answering an unseen person. A: Client is experiencing auditory
hallucinations. P: Offered prn Haldol 2 mg po. I: 2 mg Haldol po administered. E:
Client calmer. Returned to lounge and watched TV.".
d. "Client seen pacing hall and muttering to self as though answering an unseen
person. Haldol 2 mg po administered at 9 AM with calming effect in 30 minutes.
Stated he was no longer ‘bothered by the voices.'"
ANS: C
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective
data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation.
Option A is an example of PIE charting. Option B is an example of focus documentation. Option D
is an example of narrative documentation.
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