Soap charting Study guides, Class notes & Summaries

MNT Exam 1 Questions With Verified And Updated Answers. What are the 4 steps involved in the NCP - answerNutrition Assessment Nutrition Diagnosis Nutrition Intervention Nutrition monitoring and evaluation SOAP - answerSubjective Objective Assessment Plan ADIME - answer(Nutrition) Assessment Diagnosis Intervention Monitoring and Evaluation Nutrition Assessment - answercollect and organize information Identify medical problems and issues that may impact nutritional status Prioritize the ...

Charting by exception (CBE) Answer focuses on documenting deviations limited usefulness when trying to prove that high-quality safe care was given if a negligence claim is made against nursing. Focus Charting Format Answer Brings focus of care to patient specified concern. Data Action Response when can PHI be shared w/o authorization? Answer Public health activities: Disease outbreaks/infection control Law enforcement/Judicial proceedings (legal order) Death: Coroners/victim of crime no...

PNR 104 Exam #2 Questions and Answers 100% Solved Steps of the nursing process in order Assessment, nursing dx, planning, implementation, and evaluation Assessment and nursing DX RN's are responsible for this part of the nursing process Data Collection LPN's main role in nursing process Documentation of the plan Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs....

Ch 16, 19Identify the purposes of the client record - Communication among health professionals, Education of health professionals, Legal documentation detailing the client's care, Quality assurance, Identification of the cost of care, Health research What are the key differences between source-oriented and problem-oriented records? - The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is orga...

the ___ is federal legislation that protects personal information, including health information correct answers Personal Information Protection and Electronic Documents Act (PIPEDA) a patient's ___, or chart, is a confidential, permanent legal document of information relevant to a patient's health care correct answers record ___ are oral, written, or audiotaped exchanges of information between caregivers correct answers reports quality documentation has six important characteristics: ...

1. What aspects of the therapeutic nurse Client relationship is addressed in the article "lend an ear"?: Ans- Trust and respect 2. What is one way a nurse violates the nurse client relationship?: Ans- When we don't listen. 3. What is the goal behind listening according to Broeder-morin and land?: - Ans- Gain empathetic understanding 4. How does a nurse show they are listening?: uncrossed, facial expression, touch, warmth Eye contact, arms 5. What are the client consequences o...

Critical Thinking (definition)- - correct answer Critical thinking is required to use the nursing process successfully.• Critical thinking means requiring careful judgment.• Critical thinking is directed purposeful mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are met Essential for evaluation purposes Clinical reasoning Charting by exception - correct answer use of predetermined standards and norms to record only significant assessment care...

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...

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...

1. What aspects of the therapeutic nurse Client relationship is addressed in the article "lend an ear"?: Ans- Trust and respect 2. What is one way a nurse violates the nurse client relationship?: Ans- When we don't listen. 3. What is the goal behind listening according to Broeder-morin and land?: - Ans- Gain empathetic understanding 4. How does a nurse show they are listening?: uncrossed, facial expression, touch, warmth Eye contact, arms 5. What are the client consequences o...