Your Facility Is Using a Paper-Based Record

question 40

Multiple Choice

Your facility is using a paper-based record. The HIM department has decided to switch from an integrated record to a completely source-oriented record, postdischarge. You are responsible for training the staff members who assemble the records into the correct order. Which of the following must exist in order to implement this change?

• A) All documentation must be changed to reflect the new order.
• B) Except for physician's orders, physicians and nurses cannot document on the same page.
• C) Nothing has to change; the way the clinicians document information is irrelevant to the chart order.
• D) Physicians and nurses must document on the same page.

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Definitions:

Disconfirming Response

A communication pattern that rejects or invalidates a person's self-concept.

Impervious Response

A form of non-responsive or dismissive communication in which one ignores or does not react to someone else's communication.

Confirming Response

Statement that causes another person to value himself or herself more.

Supportive Response

A reply or reaction that provides emotional or practical help, underpinning someone's feelings or actions.