Writing soap notes Study guides, Class notes & Summaries

What are four things good case notes do? - correct answer Represent the client's situation; provide a record of client care; enable an action to be taken based on their review; and can be used in court, in school, by social agencies, and by insurance companies To whom is documentation critical? - correct answer Clients and family members; health care providers; employers and managed care companies; and licensing and accredit...

What does the S in SOAP stand for - correct answer Subjective: Describes the patients condition in a narrative form. How they describe what they're feeling What does the O in SOAP stand for - correct answer Objective: Documents and traceable facts about the patients status What does A in SOAP stand for - correct answer Assessment: the physicians medi...

HESI Comprehensive Exit Exam Answered A+ Solution Guide.2023 1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours Correct 2-A client is scheduled to undergo an upper gastrointesti...

2023 PTTC EXAM ACTUAL EXAM QUESTIONS AND CORRECT ANSWERS|ALREADY GRADED A+ Narrative - ANSWER- written description of patients visit in chronological order SOAP note. Charting - ANSWER- method that tracks subjective, objective assessment and plan for a patient's visit. Subjective - ANSWER- patient's statements ( chief complaints) Objective - ANSWER- observations made by the medical assistant, examination findings and vital signs. Assessment - ANSWER- doctor's diagnosis Plan ...

PTTC TERMS ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ A Physical Therapy Technician/Aide may perform some or all the following duties - ANSWER- Carrying out non-technical duties of physical therapy, Preparing treatment areas, Ordering devices and supplies The following are settings in which they work: - ANSWER- Schools, Clinics, General Private Practices, Acute Care Hospitals, Nursing Homes,Sub Acute Facilities and Rehabilita...

Billing and Coding Final Exam Questions And Answers (Verified And Updated) A claims assistance professional (CAP) acts as an informal representative of patients and helps patients interpret insurance contracts. - answerFalse Which level of education is generally required for one who seeks employment as an insurance coder? - answerc) Completion of an accredited program for coding certification The amount of money an insurance billing specialist earns is dependent on which factors? - answer...

A Physical Therapy Technician/Aide may perform some or all the following duties - Answer Carrying out non-technical duties of physical therapy, Preparing treatment areas, Ordering devices and supplies The following are settings in which they work: - Answer Schools, Clinics, General Private Practices, Acute Care Hospitals, Nursing Homes,Sub Acute Facilities and Rehabilitation Centers Good listeners apply the following skills: - Answer Face the person, have good eye contact, lean toward the ...

ATI RN COMPREHENSIVE PREDICTOR FORM A QUESTIONS AND ANSWERS BEST FOR 2023(RATED A+) 1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Vomiting b. Hypertension c. Epigastric pain d. Contractions 2. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. S...

Billing and Coding Final Exam Questions And Answers (Verified And Updated) A claims assistance professional (CAP) acts as an informal representative of patients and helps patients interpret insurance contracts. - answerFalse Which level of education is generally required for one who seeks employment as an insurance coder? - answerc) Completion of an accredited program for coding certification The amount of money an insurance billing specialist earns is dependent on which factors? - answer...