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?

Question

Quizplus · Accepted Answer

CIn a source-oriented medical record, documentation is organized by the source of the documentation, meaning each healthcare professional or department documents in a separate section. Therefore, B is correct because it emphasizes the separation of documentation between physicians and nurses, aligning with the source-oriented approach. C is also correct because the way clinicians document (the content and style of their notes) does not need to change for the implementation of a source-oriented record system; what changes is how the documentation is organized post-discharge, not the documentation process itself.

Your Facility Is Using a Paper-Based Record