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Documentation System
Documentation System ( 5 Questions)
A nurse is reviewing the documentation system of a client’s chart.
Which of the following is an advantage of using a source-oriented record?
It does not encourage collaboration among health care providers.In fact, a source-oriented record may hinder communication and coordination of care because the data are fragmented and scattered throughout the chart.
It does not organize the data according to the client’s problems.A problem-oriented medical record (POMR) is a different type of documentation system that arranges the data based on the problems identified by the health care team.The POMR has four components: database, problem list, plan of care, and progress notes.
It does not track the status of each problem using a problem list.This is also a feature of the POMR, not the source-oriented record.A problem list is a numbered list of the client’s current and resolved problems that serves as an index to the progress notes.
It keeps data from each person or department in a separate section.A source-oriented record is a type of documentation system that organizes the data according to the source of information, such as the physician, nurse, laboratory, or physical therapy.This format has the advantage of making it easy to locate and trace the information from each person or department who provided care to the client.
It keeps data from each person or department in a separate section. A source-oriented record is a type of documentation system that organizes the data according to the source of information, such as the physician, nurse, laboratory, or physical therapy. This format has the advantage of making it easy to locate and trace the information from each person or department who provided care to the client.
Choice A is wrong because it does not encourage collaboration among health care providers. In fact, a source-oriented record may hinder communication and coordination of care because the data are fragmented and scattered throughout the chart.
Choice B is wrong because it does not organize the data according to the client’s problems. A problem-oriented medical record (POMR) is a different type of documentation system that arranges the data based on the problems identified by the health care team. The POMR has four components: database, problem list, plan of care, and progress notes.
Choice C is wrong because it does not track the status of each problem using a problem list. This is also a feature of the POMR, not the source-oriented record. A problem list is a numbered list of the client’s current and resolved problems that serves as an index to the progress notes.