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