The nurse makes chronological entries in a client's chart that include documentation about the routine care provided, assessment findings, and client problems during a 12-hour shift. Which type of charting is this nurse completing?
1. Problem-oriented recording
2. Source-oriented recording
3. Narrative charting
4. Plan of care
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. The 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: The plan of care is part of the problem-oriented medical record.
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