Writing soap notes Study guides, Class notes & Summaries

HESI Community Test Bank 2022 1000+ Questions and Answers Updated, A+ Guide. 1. During a two-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: temperature 101.8°F, blood pressure 100/50, heart rate 104 beats/minute, and respirations 18 breaths/minute. Which action should the nurse take? a. Determine the client's current oxygen saturation rate. b. Inst...

HESI RN LEADERSHIP QUESTIONS & ANSWERS 2023/2024 UPDATE HESI RN LEADERSHIP 2023 UPDATE 1. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be inserted. b. Document the client’s refusal in the chart. c. Assess the client for uri...

ATI Comprehensive Exit Exam - 180 Correct Questions & Answers 2022/2023 EXIT EXAM 1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate? a. “You don’t have to go through with the treatment.” b. “Most people who have this procedure feel better following the treatment.” c. “It’s okay to be nerv...

NU 131 - Test 1 - Chapters 4, 14, 1, 5, and 12 with100% Correct Answers Founded in ___________ by the Lutheran Order of Deaconesses - Answer- 1836 in Kaiserswerth, Germany Most popular student was _______________________ - Answer- Florence Nightingale Florence Nightingale became a superintendent of the Institution for the Care of Sick Gentlewomen in Distressed Circumstances and renamed it the ________________________________ - Answer- Harley Street Nursing Home Florence Nightingale insta...

NU 131 - Test 1 - Chapters 4, 14, 1, 5, and 12 Questions With Correct Answers Founded in ___________ by the Lutheran Order of Deaconesses - ANSWER 1836 in Kaiserswerth, Germany Most popular student was _______________________ - ANSWER Florence Nightingale Florence Nightingale became a superintendent of the Institution for the Care of Sick Gentlewomen in Distressed Circumstances and renamed it the ________________________________ - ANSWER Harley Street Nursing Home ...

RHIT FINAL EXAM PRACTICE QUESTIONS WITH COMPLETE SOLUTION 2023/2024 100% CORRECT. The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an) AMA-approved product Certified EHR Joint Commission-approved system Functional EMR - Answer Certified EHR In prepar...

NUFT 204 Exam Questions and Answers Latest Updated 2024/2025 (100% Solved) Current health or history of current illness - HPI (history of present illness 4.Past health 5.Family history 6.Review of systems - Head to toe 7.Functional assessment or ADLs " Examples of Biographical data in health hstory - ANSWER "Name •Address and phone number •Age and birth date •Birthplace •Sex •Marital status •Race •Ethnic origin •Occupation—usual and present •Source of informa...

What is a SOAP note? - correct answer A common documentation style used by healthcare providers that's written to outline and manage drug related problems What does SOAP stand for? - correct answer Subjective Objective Assessment Plan What does FARM stand for? - correct answer Findings (S/O) Assessment Recommendations Monitoring What does DA...

What is a SOAP Note? - correct answer Commonly utilized format for documentation in patient medical record Components of SOAP Note - correct answer S - Subjective O - Objective A - Assessment P - Plan What are the 3 steps in writing a SOAP note? - correct answer 1. Collect patient data 2. Analyze available information 3. Formulate an assessment ...

What are the 5 Objectives of Intervention? 1. Client should show improvement not just in a clinical setting; Progress should be generalized to real-world environments. 2. Should be automatic 3. Should be self-monitored 4. Should make optimum progress in minimum amount of time 5. Intervention should be sensitive to personal and cultural characteristics. Treatment Protocol Written guideline that specifies therapy frequency, duration, and type of service. Also has goals, skilled interv...