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PHAS Exam 2: Clinical documentation Questions With Complete Solutions
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PHAS Exam 2: Clinical documentation Questions With Complete Solutions
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PHAS Exam 2: Clinical documentation Questions WithComplete Solutions
5 mg and 0.5 mg Correct Answer how to write five mg and five
tenths mg
ADC VACANT DIMPLES Correct Answer admit and post-op
orders acronym
additional labs and diagnostic testing, consults, therapy, health
promotion/prevention, patient education, disposition (where
they're going), follow up Correct Answer Plan of Care 7
inclusions
admit to: type of unit and admitting physician, diagnosis, and
condition (stable, fair, critical) Correct Answer ADC
after physical exam findings, list test then results, only ones
done at time of visit documented under O (after done in P)
Correct Answer how to document lab/diagnostic testing
assessment- diagnosis Correct Answer A of SOAP
best rest, ad lib, up with assistance Correct Answer activity
examples
black ink, date and military time, signature, single line through
errors with explanation and D/T Correct Answer basic
principles of documentation
CBC, CMP, UA, coagulation Correct Answer labs examples
, CC, HPI, PMH, FH, SH, ROS Correct Answer 6 examples of
subjective info
complete history and PE, diagnostics, assessment (DDx and
problem list), treatment plan Correct Answer comprehensive H
and P components (5)
conclusion from S and O, most specific known at that time, may
use symptoms if cannot be concluded Correct Answer how to
document Assessment
diagnosis, procedure, purpose of procedure, alternatives,
risks/benefits, possible need for additional surgery, risk of not
getting surgery Correct Answer Pre-op surgeon must discuss
(7)
diet, IV fluids, medications, procedures, labs, ECG or echo,
studies/imaging Correct Answer DIMPLES
disposition, activity, bathing/wound care, diet, medications,
follow-up instructions, notification instructions Correct Answer
discharge orders (7)
done within 24 hours or given verbally VS can be done 30 days
early but updated at admission Correct Answer H and P
emergency vs elective admission timeline
each diagnosis in assessment must be addressed Correct
Answer what is included in Plan of Care
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