Using the SOAP style of documenting progress notes, choose the "subjective" statement from the
patient states low back pain is as severe as it was on admission
patient moving about very cautiously, appears to be in pain
adjust pain medication; begin physical therapy tomorrow
sciatica unimproved with hot pack therapy
The old practices of flagging records for deficiencies and requiring retrospective documentation add
little or no value to patient care. You try to convince the entire health care team to consistently enter
data into the patient's record at the time and location of service instead of waiting for retrospective
analysis to alert them to complete the record. You are proposing
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk
notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is
this clerk performing?
Which method of identification of authorship or authentication of entries would be inappropriate to
use in a patient's health record?