Soap documentation - Study guides, Class notes & Summaries
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The OTA’s Guide to Documentation: Writing SOAP Notes Fifth Edition Complete all chapters Solutions.
- Exam (elaborations) • 344 pages • 2024
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Complete 2024, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. 
 
The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required fo...
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ATI RN COMPREHENSIVE EXIT EXAM TEST BANK 2023 COMPLETE REVISED QUESTIONS & ANSWERS.
- Exam (elaborations) • 239 pages • 2023
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ATI RN COMPREHENSIVE EXIT EXAM TEST BANK 2023 COMPLETE REVISED QUESTIONS & ANSWERS. 
Link to Quizlet: 
diet for chronic renal failure 
low protein & potassium 
DM pt teaching 
change shoes, wash feet w/soap & water 
pulse pressure 
subtract systolic value from diastolic value 
lantus 
never mix, long lasting, no peak 
rhogam 
given @ 28 weeks & 72 hours post delivery 
when mom is negative & baby positive 
indication of baby dehydration improving 
smooth fontanel 
pt w/orthostatic hypotension 
pu...
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HESI Health Assessment EXAM
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HESI Health Assessment EXAM 
SOAP modified format - CORRECT ANSWER Subjective 
Objective 
Assessment 
Plan 
What color ink should be used when documenting on paper - CORRECT 
ANSWER Permanent black ink 
What is the correct order for vital signs - CORRECT ANSWER T, P, RR, BP, 
extremity, pt position, SPO2 
What should be at the top of every page of documentation - CORRECT ANSWER 
Patient initials and date and time of entry 
What should be at the end of every documentation entry - CORRECT ANS...
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HESI Health Assessment EXAM
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HESI Health Assessment EXAM 
SOAP modified format - CORRECT ANSWER Subjective 
Objective 
Assessment 
Plan 
What color ink should be used when documenting on paper - CORRECT 
ANSWER Permanent black ink 
What is the correct order for vital signs - CORRECT ANSWER T, P, RR, BP, 
extremity, pt position, SPO2 
What should be at the top of every page of documentation - CORRECT ANSWER 
Patient initials and date and time of entry 
What should be at the end of every documentation entry - CORRECT ANS...
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Nursing Documentation & Informatics Questions and Answers Already Passed
- Exam (elaborations) • 19 pages • 2024
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Nursing Documentation & Informatics 
Questions and Answers Already Passed 
 
Which of the following best describes an electronic health record (EHR)? 
A) A paper-based system for recording patient information 
B) A digital system used to store, manage, and retrieve patient health information 
C) A manual record-keeping method used for billing purposes 
D) A system used only for scheduling patient appointments 
 B) A digital system used to store, manage, and retrieve patient health information 
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Shadow Health Tina Jones Documentation; Electronic Health Record.
- Exam (elaborations) • 5 pages • 2023
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Shadow Health Tina Jones Documentation; Electronic Health Record. 
Health History Results | Completed 
Health Assessment - August 2017, NUR3067C 
Return to Assignment (/assignments//) 
Your Results Lab Pass (/assignment_attempts//lab_pass.p 
Overview 
Transcript 
Subjective Data Collection 
Documentation / Electronic Health Record 
Document: Provider Notes 
Objective Data Collection 
Education & Empathy 
Documentation 
Document: Provider Notes 
Student Documentation Model Documentation 
Health H...
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RN VATI COMPREHENSIVE ASSMT 2023|2024 REAL EXAM 180 QUESTIONS AND 100% CORRECT ANSWERS
- Exam (elaborations) • 34 pages • 2023
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***Download Test Bank Immediately After the Purchase. Just in case you have trouble downloading, kindly message me, and I will send it to you via Google Doc or email. Thank you*** 
 
The ATI RN Comprehensive Predictor Exam is a crucial tool for nursing students on the practical nursing track. This exam provides a detailed, comprehensive evaluation of a student's knowledge and abilities before they take the NCLEX-RN. The ATI RN Comprehensive Predictor Exam Guide offer a wide range of practice que...
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NUR 206_ATI FUNDAMENTALS EXAM, Chapters 1 to 58 | Complete Latest Summer 2023 study guide.
- Other • 53 pages • 2023
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5/3/19 ATI FUNDAMENTALS EXAM 1. CHAPTER 1: HEALTH CARE DELIVERY SYSTEMS A. Components of Health care systems a. Participants 1. Consumers- clients 2. Providers a. Licensed providers: registered nurses, license practical (or vocational) nurses (LPN), advanced practice nurses (APN), medical doctors, pharmacists, dentists, dietitians, physical/respiratory/occupational therapists, etc b. Unlicensed providers: assistive personal b. Settings 1. Hospitals, homes, skilled nursing, assisted living, schoo...
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Exam 2: PNR 104 / PNR104 (Latest 2024/ 2025 Update) Basic Skills, Quality & Safety in Nursing Practice Review| Questions and Verified Answers| 100% Correct- Grade A- Fortis
- Exam (elaborations) • 19 pages • 2024
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Exam 2: PNR 104 / PNR104 (Latest 2024/ 2025 Update) Basic Skills, Quality & Safety in Nursing Practice Review| Questions and Verified Answers| 100% Correct- Grade A- Fortis 
 
 
Q: 6 main methods of documentation 
 
 
Answer: 
source-oriented (narrative) charing, problem oriented medical record charting (POMR) focus charting, charting by exception, computer assisted charting, and case management system charting. 
 
 
 
Q: source oriented charting (narrative) 
 
 
Answer: 
narrative notes are phr...
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FIPP 5 Exam #1 Questions with Correct Answers
- Exam (elaborations) • 20 pages • 2024
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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 
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