In most hospitals, the patient record starts with the ___________________ .
A) registration process
B) initial evaluation by nursing staff
C) first physician visit
D) discharge process
Question 2
Developed by the substance abuse client's treatment team, this document is used to identify the type and frequency of services needed by the client. It includes measurable goals and objectives that address the problems identified in the clinical assessment and should be updated periodically.
A) individualized treatment plan (ITP)
B) addiction severity index (ASI)
C) history and physical (H&P)
D) progress notes (SOAP)