The omission of the planning stage of the nursing process is a disadvantage of which documentation system?
1. Problem, intervention, evaluation system
2. Problem-oriented medical record
3. Focus system
4. Electronic medical record
Problem, intervention, evaluation system
Rationale: The problem, intervention, evaluation system does not document the planning step in the nursing process, which addresses expected outcomes. In the problem-oriented medical record, after a nurse lists the client's problems, an initial plan of care is developed that includes expected outcomes, plans for further data collection, patient care, and teaching plans. The focus system includes a detailed patient assessment leading to the development of patient-centered problems that are expressed as nursing diagnoses. Subsequent documentation focuses on data-action-response. The electronic medical record utilizes nursing information systems that contain most of the components of the nursing process and therefore adheres to the Joint Commission documentation standard that care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals.
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