CARDIOVASCULAR DOCUMENTATION
EXAM PREP QUESTIONS AND ANSWERS
FULL SOLUTION
●● Health Record
Answer: Individualized collection of health information and data about a
clients health.
●● Documentation Methods
Answer: 1. Source-Oriented Medical Records.
2. Problem-Oriented Medical Records.
3. Subjective, Objective, Assessment, and Plan Charting (SOAP).
4. Problem-Intervention-Evaluation Charting (PIE).
5. Focus Charting.
6. Charting By Exception (CBE).
●● Telephone Prescription
Answer: A prescription received over the telephone from a provider
when the provider is not physically present.
●● HIPAA Privacy Rule
, Answer: Part of HIPAA. Established in 2003, it created regulations that
govern EHR (Electronic Health Records) Records to protect the privacy
of healthcare consumers.
●● Source-Oriented Medical Record
Answer: A traditional format for documenting within a medical record
for all principles.
●● Problem-Orientation Medical Record (POMR)
Answer: A more comprehensive and organized approach to recording
and reading client data.
Contains 4 components:
1. A database in which assessment data are documented.
2. A problem list that lists the clients problem chronologically.
3. An initial plan that outlines goals, expected outcomes, and further data
needed if necessary.
4. Progress notes using the SOAP (Subjective, Objective, Assessment,
Plan) format.
●● SOAP
Answer: S: Subjective. Information from client.
O: Objective. Clinical impressions recorded, what the nurse observed.
A: Assessment. Analysis of S(Subjective) and O(Objective).
P: Plan. Interventions the nurse plans to implement.
EXAM PREP QUESTIONS AND ANSWERS
FULL SOLUTION
●● Health Record
Answer: Individualized collection of health information and data about a
clients health.
●● Documentation Methods
Answer: 1. Source-Oriented Medical Records.
2. Problem-Oriented Medical Records.
3. Subjective, Objective, Assessment, and Plan Charting (SOAP).
4. Problem-Intervention-Evaluation Charting (PIE).
5. Focus Charting.
6. Charting By Exception (CBE).
●● Telephone Prescription
Answer: A prescription received over the telephone from a provider
when the provider is not physically present.
●● HIPAA Privacy Rule
, Answer: Part of HIPAA. Established in 2003, it created regulations that
govern EHR (Electronic Health Records) Records to protect the privacy
of healthcare consumers.
●● Source-Oriented Medical Record
Answer: A traditional format for documenting within a medical record
for all principles.
●● Problem-Orientation Medical Record (POMR)
Answer: A more comprehensive and organized approach to recording
and reading client data.
Contains 4 components:
1. A database in which assessment data are documented.
2. A problem list that lists the clients problem chronologically.
3. An initial plan that outlines goals, expected outcomes, and further data
needed if necessary.
4. Progress notes using the SOAP (Subjective, Objective, Assessment,
Plan) format.
●● SOAP
Answer: S: Subjective. Information from client.
O: Objective. Clinical impressions recorded, what the nurse observed.
A: Assessment. Analysis of S(Subjective) and O(Objective).
P: Plan. Interventions the nurse plans to implement.
