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
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.
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