Emr soap note - Study guides, Class notes & Summaries

YOOST & CRAWFORD FUNDAMENTALS OF NURSING: ACTIVE LEARNING FOR COLLABORATIVE PRACTICE, 2ND EDITION FOR MORE MATERIALS- Chapter 10: Documentation, Electronic Health Records, and Reporting MULTIPLE CHOICE 1. The nurse understands the need for accurate documentation due to which fact? a. Accurate documentation is needed for proper reimbursement. b. Accurate documentation must be electronically generated. c. Accurate documentation does not include e-mails or faxes. d. Accurate documentati...

Nursing practice Exam 3 1st semester 134 Questions with Verified Answers A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? a) Study the discharge plan. b) Check the graphic data for vital signs. c) Examine the history and physical examination. d) Look for an advance directive. - CORRECT ANS...

CCMA EXAM 2021 (NHA) CELL STRUCTURES IS THE SOURCE OF ENERGY FOR A CELL? - ANS MITOCHONDIRA A MA IS TESTING A PATIENT'S VISUAL ACUITY USING A SNELLEN CHART. WHICH ACTIONS SHOULD MA TAKE? - ANS MAKE SURE THE PATIENT DOES NOT LEAN FOWARD DURING THE TEST. DURING A ROUTINE VENIPUNCTURE. THE PATIENT BECOMES PALE & DIAPHORETIC. WHAT CONDITION IS MOST LIKELY TO OCCUR IN THIS PATIENT? - ANS SYNCOPE A PATIENT CALLS THE CLINIC TO CANCEL A POSTOPERATIVE APPOINTMENT & STATES THAT ...

NHA CCMA practice test 2023 QUESTIONS AND ANSWERS Graded A Which of the following cell structures is the source of energy for a cell? - ANSWER mitochondria A medical assistant is testing a patients visual acuity using a snellen chart. Which of the following actions should the assistant take? - ANSWER Make sure the patient does not lean forward during the test Which of the following items included on the CMS-1500 claim form should a medical assistant recognize as indicating the medical ...

EMT Exam #1 (chapters 1-11) Questions with accurate answers, rated A+ What are the four levels of EMS? - -EMR, EMT, AEMT, Paramedic How many bones make up the face? - -14 What is the only movable facial bone? - -Mandible Where is the radial pulse found? - -Wrist Who can use an AED? - -Anyone, but if a medical provider need to be certified in CPR/AED What is the scope of practice for EMRs? - -Use basic airway, ventilation/oxygen therapy devices, takes vital signs, provides sta...

NHA CCMA Practice Test Questions Where do cardiac electrical impulses originate in the heart? - ANS sinoatrial node According to the regulation of controlled substances, which of the following is true of a schedule 1 drug - ANS Have no accepted medical use A medical assistant is collecting a health history from an older adult patient who exhibits moderate hearing loss. which of the following actions should the assistant take. - ANS Remain within the patien...

Scribeamerica Outpatient Final exam 2023 | 100 Questions And Answers Latest Updates. What does "PHI" stand for? Expand the abbreviation - answers-protected health information What medical term describes the surgical removal of the gallbladder? - answerscholecystectomy T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case - answers-False A patient's PCP is on vacation. The patient is scheduling to see the NP who...

Application service provider - answer-A third-party entity that manages and distributes software-based services and solutions to customers across a wide area network (WAN) from a central data center. Assessment (A) - answer-Judgement, opinion, or evaluation made by a healthcare provider; considered part of the problem-oriented record (POR) SOAP note. Assumption coding - answer-inappropriate assignment of codes based on assuming, from a review of clinical evidence in the patient's record, ...

* What medical term describes the surgical removal of the gallbladder? cholecystectomy What does "PHI" stand for? Expand the abbreviation. Protected Health Information 00:19 01:33 T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? craniotomy A pa...

NREMT Cognitive Exam Prep. Questions and answers. 100% proven pass rate. Graded A+ Document Content and Description Below Where does the modern EMS system have its origin? - The modern EMS system has its origins in funeral homes, which often operated ambulances. However, funeral home operators were often serving co mpeting business interests and patients received little trained care until the hospital. What is considered the "birth" of EMS? - In 1966, a paper titled "Accidental Death and Di...