When attempting to locate recent lab results, the new nurse ...

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

Question 2

The nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In which section would the nurse find the most recent physician orders?
 
  1. Database
  2. Problem list
  3. Plan of care
  4. Progress notes

[dominiqueenicolee]

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: The database consists of all known information about the client upon admission.
Rationale 2: The problem list includes all identified problems, listed in the order in which they are identified.
Rationale 3: The initial list of orders or plan of care is made with reference to the client's active problems in this type of charting. Physicians write physician orders or the medical care plan.
Rationale 4: Progress notes are chart entries made by all health professionals involved in the client's care.

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Gracias!

[xiaomengxian]

Thanks for the timely response, appreciate it