RCTX 3254 TEST 2 2026/2027 | COMPLETE STUDY GUIDE, PRACTICE QUESTIONS
& EXAM REVIEW
weight, BP, & appetite - ANS ✔✔What are daily vital signs? (monitoring)
1.) How did we receive the patient (referral)
2.) Treatment plan
3.)assessment/diagnosis
4.) Connection of treatment plan to assessment
5.) medication or medical change
6.) On-going service delivery - ANS ✔✔What content do RTs include when documentation?
1.) narrative format 2.) focus charting 3.) SOAP (problem-oriented) 4.) BIRP (behavioral) - ANS
✔✔Common Methods in Charting
Problem-oriented Record Keeping (POMR)
Free Form Narrative Format
Alternate Streamline Documentation - ANS ✔✔3 General Documentation Methods
-Data base or initial assessment
-Client problem list
-Initial treatment plan
-Progress notes
-Discharge summary
, (SOAP NOTES ARE OFTEN USED IN POMR) - ANS ✔✔POMR Includes
Free Form Record Keeping - ANS ✔✔-Most basic form
-Best for community
-based services
-Example: Journaling
Critical Pathway/Health Care Maps - ANS ✔✔-Provide the sequence and timing of actions
necessary to achieve goals
-Focused on optimal efficiency (MANAGEMENT CARE PLAN)
Variance - ANS ✔✔NOT on critical pathway. The idea is that all patients are on a path and those
that vary will need to provide a variance.
Flow Sheets - ANS ✔✔Graphic (aka visual) record to see the status of an individual. (Example:
Food intake & Output)
P= problems (labeled given a number)
I= Intervention
E= Evaluation
24-Hour flow sheet combined with progress notes - ANS ✔✔PIE
Charting By Exception (CBE) - ANS ✔✔a system of charting in which only significant findings or
exceptions to standards or norms of care are recorded or charted
false - ANS ✔✔Receiving a referrals for RT service should only be documented in progress notes
when the service is ACCEPTED by the RT clinician. (T or F)
& EXAM REVIEW
weight, BP, & appetite - ANS ✔✔What are daily vital signs? (monitoring)
1.) How did we receive the patient (referral)
2.) Treatment plan
3.)assessment/diagnosis
4.) Connection of treatment plan to assessment
5.) medication or medical change
6.) On-going service delivery - ANS ✔✔What content do RTs include when documentation?
1.) narrative format 2.) focus charting 3.) SOAP (problem-oriented) 4.) BIRP (behavioral) - ANS
✔✔Common Methods in Charting
Problem-oriented Record Keeping (POMR)
Free Form Narrative Format
Alternate Streamline Documentation - ANS ✔✔3 General Documentation Methods
-Data base or initial assessment
-Client problem list
-Initial treatment plan
-Progress notes
-Discharge summary
, (SOAP NOTES ARE OFTEN USED IN POMR) - ANS ✔✔POMR Includes
Free Form Record Keeping - ANS ✔✔-Most basic form
-Best for community
-based services
-Example: Journaling
Critical Pathway/Health Care Maps - ANS ✔✔-Provide the sequence and timing of actions
necessary to achieve goals
-Focused on optimal efficiency (MANAGEMENT CARE PLAN)
Variance - ANS ✔✔NOT on critical pathway. The idea is that all patients are on a path and those
that vary will need to provide a variance.
Flow Sheets - ANS ✔✔Graphic (aka visual) record to see the status of an individual. (Example:
Food intake & Output)
P= problems (labeled given a number)
I= Intervention
E= Evaluation
24-Hour flow sheet combined with progress notes - ANS ✔✔PIE
Charting By Exception (CBE) - ANS ✔✔a system of charting in which only significant findings or
exceptions to standards or norms of care are recorded or charted
false - ANS ✔✔Receiving a referrals for RT service should only be documented in progress notes
when the service is ACCEPTED by the RT clinician. (T or F)
