The nursing instructor teaches students about source-oriented medical records.Which labeled tabs should the instructor emphasize? Select all that apply.
A)Nurse's notes
B)Care plan
C)Graphic data
D)Physician's orders
E)Rehabilitation therapy

Question

Quizplus · Accepted Answer

Source-oriented medical records are organized by the source of information, meaning each healthcare professional or department documents in a separate section. Nurse's notes (A), graphic data (C) like charts and vital signs, physician's orders (D), and rehabilitation therapy (E) notes are all examples of documentation that would be found in separate sections of a source-oriented medical record. The care plan (B), while an important part of the medical record, is typically a collaborative document rather than a source-specific document.

The Nursing Instructor Teaches Students About Source-Oriented Medical Records