Adult soap note - Study guides, Class notes & Summaries

PURPOSES OF DOCUMENTATION Correct Answer-• Improving patient care & outcomes.• Providing patients with information about their care.• Enhancing continuity of care.• Ensuring compliance with laws & regulations.• Protecting against professional liability.• Creating a record of services provided for billing & reimbursement purposes. • Establishing the pharmacist's credibility as a health care provider. SOAP Note stands for: Correct Answer-subjective, objective, assessment, plan ...

NURS 5220 / NURS5220 ADULT SOAP NOTE GRADED A+ / NURS 5220 / NURS5220 ADULT SOAP NOTE GRADED A+

566 Final Exam Study Guide Week 5 Prevention of osteoporosis with hormone replacement therapy (p. 433) Hormone therapy (HT) reduces postmenopausal bone loss & thereby decreases the risk for osteoporosis & related fractures. Unfortunately, when HT is stopped, bone mass rapidly decreases by approximately 12%. Hence to maintain bone health, HT must continue lifelong. As a result, the risk for harm is increased. Accordingly, alternative treatments are preferred. Effective alternatives to HT include...

Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only after leaving each room. 4) uses cold water for medical asepsis. 2. What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of...

Fundamentals CMS Midterm Terms in this set (200) A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high- pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub A nurse is obtaining ...

Paroxysmal nocturnal dyspnea: - awakening from sleep with SOB and needing to be upright to achieve comfort Electronic health record: - Systematic collection of a patient's health care and treatment in a digital format Mistakes in documentation that commonly result in malpractice: - - failing to record pertinent health or drug information - failing to record nursing actions - failing to record medication administration - failing to record drug reactions or changes in patient's condition...

A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. ...

HESI Fundamentals Exam V6 (VERSION 6) (130 Questions with Answers) (2023/2024) (Graded A+) HESI Fundamentals Exam V6 (VERSION 6) 1. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." 2. A nurse is caring for a client who is postoperative and h...

HESI RN EXIT EXAM V1-V7 (LATEST ) / RN EXIT HESI EXAM V1,V2,V3,V4,V5,V6,V7 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? • Review with the client the need to avoid foods that are rich in milk and cream 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns ...

SOAP Note Form Adult Management I S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx: D. T., 02/12/1975, Female, Reliable historian Paternal Lung Cancer, Maternal Diabetes Personal/Social Chief Complaint/RFE: Hx: Divorced, lives at home with one teenage child, no history of tobacco, ETOH, or illicit drug use Cough, congestion, sore throat, flu two weeks ago Hx Present Illness: (7 Variables but do not list as such) Patient was diagnosed with the flu two w...