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PC716 Physical Assessment Exam 1 (100- correct answer).
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PC716 Physical Assessment Exam 1 (100- correct answer).
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PC716 PhysicalAssessment Exam 1
(100% correct answer)
What are all the sections of the Comprehensive
Health Visit and it's documentation? - answer
Comprehensive Health Visit and its Documentation
means the provider does everything.
S:
CC
HPI
Active Medical History
Past Medication History (childhood/adult illness
resolved, surgical, accidents, women's health,
psychiatric, health maintenance)
Medications
Allergies
Immunizations
Family History (3 generations)
Social History
ROS (complete of every system)
,O:
Physical Exam (a complete head to toe exam
appropriate for patient)
Labs & Diagnostics (available at the time of the
visit)
A:
Medical Diagnosis or Diagnoses that can be coded
and billed for
P:
Diagnostics (that need to be done but not available
at visit)
Therapeutics (treatments or prescriptions)Patient
Education
Follow-up (why do they need to return)Referral
What is the same but different about
Comprehensive and Episodic Health Visits and their
documentation? - answer Both the comprehensive
and episodic/focused visit rely on the SOAP
Framework for the order of the visit and the
documentation. The comprehensive requires the
provider to collect all elements of the history and
complete head to toe physical exam to arrive at an
appropriate diagnosis and plan of care. Common
, reasons for a comprehensive visit is establishing
care, preventative visit, employment physical, etc.
The episodic/focused however allows the provider
to only collect data they feel is appropriate to
evaluate the concern the patient has presented for
in turn leading to a hypothesis driven physical
exam based on that history, and then arriving at a
diagnosis (assessment), and a plan of
management.
How can you tell subjective and objective apart? -
answer Subjective data is just that what the
patient says. I imagine myself as the provider with
my eyes closed and my hands in my pockets. The
only way I gather data is by what the patient tells
me. This also includes subjective only screening
tools.
Objective data is when the provider
observes/inspects, palpates, percusses, or
auscultates. Objective data is also diagnostic
results or clinical/screening tools utilizing objective
data.
What are the three ways the SOAP Framework is
used? - answer 1. Order the patient visit. First
gathering history (S), then completing an exam
(O), then sitting down with the patient to discuss
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