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Which nursing documentation best meets the requirement for problem-oriented charting?
A. "Pacing and muttering to self. Sensory perceptual alteration related to internal auditory stimulation. Given fluphenazine 2.5 mg PO at 0900 and went to room to lie down. Calmer by 0930. Returned to lounge to watch TV."
B. "Agitated behavior. Patient muttering to self as though answering an unseen person. Given haloperidol 2 mg PO and went to room to lie down. Patient calmer within 30 minutes. Returned to lounge to watch TV."
C. "Pacing hall and muttering to self as though answering an unseen person. Haloperidol 2 mg PO administered at 0900, with calming effect in 30 minutes. Stated 'I'm no longer bothered by the voices.'"
D. "S: States 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg PO. I: Haloperidol 2 mg PO given at 0900. E: Returned to lounge at 0930 and quietly watched TV."

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Answer:

D. "S: States 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg PO. I: Haloperidol 2 mg PO given at 0900. E: Returned to lounge at 0930 and quietly watched TV."

Explanation:

Problem-oriented charting in Nursing Science is a type of medical documentation in which a Patient’s data is organized according to a stated diagnosis. It is also known as Problem-Oriented Medical Record (POMR).

There are four main components of a POMR:

1. A database

2. A list of problems

3. A plan of action

4. A note on progress

A POMR is not considered complete if it doesn’t contains sufficient information to identify the patient; support the diagnosis; justify the care that was given; document the results of the care given; and promote continuity of the care amongst healthcare providers.