Source-Oriented Health Record - ACCURATE ANSWERS Documents organized into sections according to the provider's and departments that provide treatment (lab together, rad. together, clinical notes together)
Problem-Oriented Health Record - ACCURATE ANSWERS Divided into four parts: database, proble...
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Source-Oriented Health Record - ACCURATE ANSWERS✔✔
Documents organized into sections according to the provider's and
departments that provide treatment (lab together, rad. together, clinical
notes together)
Problem-Oriented Health Record - ACCURATE ANSWERS✔✔
Divided into four parts: database, problem list, initial plan, progress
notes (SOAP)
SOAP what does S stand for? - ACCURATE ANSWERS✔✔ Subjective
(patient's point of view)
SOAP what does O stand for? - ACCURATE ANSWERS✔✔ Objective
(what the practitioner finds)
SOAP what does A stand for? - ACCURATE ANSWERS✔✔
Assessment (combine subjective and objective to make a conclusion)
SOAP what does P stand for? - ACCURATE ANSWERS✔✔ Plan
(approach to be taken to resolve patient's problem
Integrated Health Records - ACCURATE ANSWERS✔✔
Documentation from various sources organized in strict chronological or
reverse chronological order
, Advantage of Integrated Health Record? - ACCURATE ANSWERS✔✔
Easy to follow course of diagnosis and treatment
Disadvantage of Integrated Health Record? - ACCURATE
ANSWERS✔✔ Difficult to compare similar information (ex. lab results
or oncology information)
When should H&P be documented in record? - ACCURATE
ANSWERS✔✔ Within 24 hours of admission
When should Operative Report be documented in record? - ACCURATE
ANSWERS✔✔ Immediately following surgery
When should Verbal Orders be cosigned? - ACCURATE
ANSWERS✔✔ Within 24 hours
When should Discharge Summary be documented? - ACCURATE
ANSWERS✔✔ Immediately after discharge of patient
Qualitative Analysis - ACCURATE ANSWERS✔✔ Review of record to
ensure that standards are met and determine the adequacy of entries
documenting the quality of care
Quantitative Analysis - ACCURATE ANSWERS✔✔ A review of health
record to determine its completeness and accuracy
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