Medical nutrition therapy strategies would be listed in which section of the SOAP note?
a. S
b. O
c. A
d. P
Q. 2A statement regarding the patient's nutritional status at this time would be recorded in which section of the SOAP note?
a. S
b. O
c. A
d. P
Q. 3Your patient has just had labs drawn and there is an abnormal value. You would record this in which section of the SOAP note?
a. S
b. O
c. A
d. P
Q. 4Which of the following is an acceptable medical abbreviation?
a. U
b. BID
c. QD
d. 4.0 mL
Q. 5Data such as patient reports of nausea or vomiting would be recorded in which section of the SOAP note?
a. S
b. O
c. A
d. P
Q. 6Of all of the different styles of charting, which one is the most well known?
a. POMR
b. SOAP
c. IER
d. Focus notes
Q. 7Long-term care facilities that are receiving patients from the hospital would be most interested in which portion of the medical record?
a. the progress notes
b. the teaching plan
c. the problem list
d. the discharge summary
Q. 8Which of the following is not part of the POMR medical record?
a. data
b. progress note
c. interdisciplinary treatment plan
d. discharge summary