Soap documentation - Study guides, Class notes & Summaries

Purpose of EMS system - Answer-Formal system of care to respond to medical emergencies Typical seq. of events from emergency --> EMS activated --> pt. transfer to hospital - Answer-1. 911 called 2. Dispatcher provides verbal help, dispatches EMR 3. EMR responds and may call for backup 4. Pt. may be transferred to hosp Two basic ways to access the EMS system - Answer-1. 911 2. Non-911 Nationally recognized levels of training in the EMS system - Answer-1. EMR 2. PCP 3. ACP 4. CCP ...

DD Form 689 Individual sick call slip that initiates the sick call process Used for patient who requests or receives medical/dental evaluation or treatment at an Army Medical Treatment Facility (MTF) used as a means of communication between medical personnel and the patient's commander SF 600 Chronological Record of Medical Care form used to document the chronological record of the patient's treatment Should include: - Date and time of visit - Medical Treatment Facilit...

FOUNDATIONS AND ADULT HEALTH NURSING 9TH EDITION COOPER GOOSNELL TEST BANK CHAPTER 1-41 | COMPLETE GUIDE A+ 2023-2024. Which of the following must the nurse recognize regarding the health care delivery system? a. It includes all states. b. It affects the illness of patients. c. Insurance companies are not involved. d. The major goal is to achieve optimal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal lev...

NR 565 Week 6 Asthma Case Study Q&A.The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by NPs and other healthcare professionals and includes: S: subjective information provided by the patient O: objective information obtained by the provider A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information has already been provided to you in the case. P: medical plan. Write a brief SOAP note addressing Haley’...

(The correct answer has been verified, selected and highlighted in yellow for all of the questions below.) 1 What form is used to submit a provider’s charge to the insurance carrier? a. ABN b. UB-04 c. CMS-1500 d. Provider reimbursement form 2 AAPC credentialed coders have proven mastery of what information? a. Code sets b. Evaluation and management principles c. Documentation guidelines d. All of the above 3 When coding an operative report, what action would NOT be recommended? a....

The brain and spinal cord are included in which of the following? Central nervous sytsem The cranial nerves 31 pairs of spinal nerves, and branches make up which of the following? Peripheral nervous system A rotational sensation of spinning is considered to be which of the following? Vertigo A sensation of numbness and or tingling of the extremities is referred to as which of the following? Paresthesia Lightly touching the cornea with a cotton ball would be exam...

Components of the EMS System - DISPATCHER: Coordinates type and level of EMS response and dispatches the appropriate agencies. An emergency medical dispatcher may give medical instructions to the public. - FIRST RESPONDER: Entry level medically trained person. - EMT: Provides basic life support/BLS. - PARAMEDIC: Provides advanced life support/ALS. - RECEIVING FACILITY: The medical treatment facility that provides emergency care. Primary Responsibilities As first responders, peace of...

Nurse Jalen is reviewing the electronic medical record (EMR) and is preparing for Louis's admission. To which of the following rooms should nurse Jalen anticipate Louis being assigned? - answer A private room that has an attached anteroom. Charge nurse Erika and nurse Jalen are preparing to enter the client's room. Which of the following masks should nurse Jalen ensure are available to health care personnel before entering Louis's room? - answer D When reviewing Louis's data in the ele...

HESI RN Leadership & Management Exam V1-V3 V1 - 55 Q&A 1. Charge nurse takes over for nurse on break, which client checked first -40ml dark colored urine 2. UAP stuck in palm by needle with Hepatitis B -wash hands with soap and water 3. Reading back hcp prescription, most important to implement - Initiate telemetry & obtain cardiac rhythm 4. New clinical documentation -Need to discuss new clinical documentation that helps save lives and require one more document 5. PCA to PO. BP incre...

Nurs- B260 Fundamentals Exam 2 Questions with Complete Solutions Medical Record - Correct Answer Purpose: -Facilitate interdisciplinary communication, provide a record of care, allow for auditing, monitoring, and evaluation of care provided. Also serve as sources of research data and learning resources -Used for communication, legal documentation, reimbursement for health care services, auditing and monitoring (to see if standards of care were met) Guidlines for Quality Documentation - Cor...