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?

Question

1. Source-oriented record
2. Problem-oriented record
3. Case management
4. Focus charting

Answer 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.