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In a Medical Record for a Patient Who Has Had

Question 2

Multiple Choice

In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents "Subjective: denies itching. Happy with improvement in skin.
Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge.” This type of documentation is an example of:


A) charting by exception.
B) narrative style.
C) a problem-oriented medical record (POMR) .
D) the case management system.

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