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Title: What is a time-based record of measurement during a specialized procedure such as mechanical ... Post by: vgrdiver on Feb 25, 2018 What is a time-based record of measurement during a specialized procedure such as mechanical ventilation?
a. Consultation sheet b. Specialized flowsheet c. Progress notes d. Graphic sheet Q. 2 Information about a patient's nearest kin, physician, and initial diagnosis can be found in which section of the medical record? a. History and physical exam b. Admission sheet c. Physician's orders d. Consultation sheet Q. 3 The elements of a POMR entry would include which of the following? 1. Patient's subjective complaints and concerns 2. Objective data gathered by the health professional 3. Assessment of the subjective and objective data 4. Plan to address the identified problem(s) a. 1, 2, and 3 only b. 1 and 3 only c. 1, 2, 3, and 4 d. 1, 3, and 4 only Q. 4 What form of patient record is most designed to succinctly report data in a time-oriented format and to decrease time needed for documentation? a. Subjective, objective, assessment, and plan (SOAP) record b. Problem-oriented, medical record (POMR) record c. Flowsheet d. Progress note Title: What is a time-based record of measurement during a specialized procedure such as mechanical ... Post by: impostine on Feb 25, 2018 The POMR progress notes contain the findings (subjective and objective data), assessment, plans, and orders of the doctors, nurses, and other practitioners involved in the care of the patient. The format used is often referred to as SOAP. S = subjective information; O = objective infor-mation; A = assessment; P = plan of care. Flowsheets are designed to briefly report data and to decrease time spent in documentation. |