When attempting to locate recent lab results, the student notices ...

[itsmyluck]

When attempting to locate recent lab results, the student notices that each department has a separate section in the client's chart. This type of documentation system is called which of the following?
 
  1. Source-oriented record
  2. Problem-oriented record
  3. Case management
  4. Focus charting

Question 2

A nurse makes an chronological entries in a client's chart that includes documentation about the routine care, assessment findings, and client problems provided during a 12 hour shift. This is an example of :
 
  1. Problem-oriented recording
  2. Source-oriented recording
  3. Narrative charting
  4. Plan of care

[Eunice618]

Answer to Question 1

Correct Answer: 1
Rationale 1: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart.
Rationale 2: In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information.
Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called critical pathways.
Rationale 4: Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format.

Answer to Question 2

Correct Answer: 3
Rationale 1: Problem-oriented recording is arranging the data according to the problem the client has.
Rationale 2: Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. Plan of care is part of the problem-oriented medical record.
Rationale 3: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used.
Rationale 4: Plan of care is part of the problem-oriented medical record.