National Council for Therapeutic Recreation Certification (NCTRC) Practice Exam

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What is it called when a physician or case manager creates a master list of client deficits and develops a plan of action?

A problem-oriented medical record

The correct term for when a physician or case manager creates a master list of client deficits and develops a plan of action is known as a problem-oriented medical record. This systematic approach allows healthcare providers to document and address each specific issue faced by the client, ensuring a comprehensive treatment plan is developed. The problem-oriented medical record is particularly useful in organizing the client's problems in a way that facilitates ongoing assessment, intervention, and evaluation of outcomes. In contrast, a clinical pathway refers to a structured plan of care that outlines the steps for the treatment and management of a specific condition, often used for standardizing care across different patients with similar needs but does not explicitly relate to documenting individual deficits. The case load of the physician on staff pertains to the number of patients assigned to a physician, which does not involve creating a detailed plan of action for individual client deficits. A diagnostic protocol provides guidelines for diagnosing conditions and is not focused on the comprehensive management of client needs. This highlights why the problem-oriented medical record is the most accurate answer in this context.

A clinical pathway

The case load of the physician on staff

A diagnostic protocol

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