Nursing Acceleration Challenge Exam (NACE) PN-RN Practice Test

In a source record, how is documentation typically organized?

1. All disciplines document in the same section

2. Each discipline documents in a different section

3. All documentation is done at a central location

4. All documentation must be completed at the point of care

The correct answer is: Each discipline documents in a different section

The organization of documentation in a source record is typically done with each discipline documenting in a different section. This structure allows for clear, organized, and efficient record-keeping, where healthcare providers can easily find and review information relevant to their specific discipline. By separating documentation according to the discipline responsible for the care, such as nursing, medicine, or therapy, it enhances clarity, reduces confusion, and ensures that each professional's contributions are distinctly recognized. This separation helps improve the communication between team members, facilitates better continuity of care, and ensures that all providers can access the information pertinent to their role in patient care. Maintaining organized sections for different disciplines also supports compliance with legal and regulatory standards for healthcare documentation.