Certified Coding Associate (CCA) Practice Exam

Question: 1 / 400

In a POMR progress note, where would one record a notation about a diabetic patient stating: "FBS 110 mg%, urine sugar, no acetone"?

Subjective

Objective

The correct answer is found in the Objective section of a POMR (Problem-Oriented Medical Record) progress note because this section is where measurable data, observable facts, and clinical findings are documented. In this case, the notation "FBS 110 mg%, urine sugar, no acetone" presents specific laboratory and test results pertaining to the patient's diabetes management. This information is factual and quantifiable, serving as evidence of the patient's current health status.

In the context of POMR, the Subjective section would typically include the patient’s personal experiences, concerns, or symptoms that cannot be measured directly. The Assessment section reflects the healthcare provider's interpretation or diagnosis based on the information gathered. The Plan outlines the proposed actions for treatment or follow-up care. Therefore, including the objective data in the appropriate section is crucial for maintaining accurate and informative patient records.

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Assessment

Plan

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