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
ANS: C
Flowsheets are designed to briefly report data and to decrease time spent in documentation.
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Which of the following BEST describes blunt-force trauma?
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Operative report: Pre-op diagnosis: cleft palate with cleft lip. Post-op diagnosis: cleft soft palate with bilateral cleft lip. Procedure: repair of cleft palate and cleft lip. This case would be reported with code(s) ____________________
Fill in the blank(s) with correct word