Author Question: Information about a patient's nearest kin, physician, and initial diagnosis can be found in which ... (Read 39 times)

nautica902 · **on:** Jul 16, 2018

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

Question 2

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

Sassygurl126 · **Reply #1 on:** Jul 16, 2018

Answer to Question 1

ANS: B

Answer to Question 2

ANS: C
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.