What is a soap note - Study guides, Class notes & Summaries

ScribeAmerica OP Final Exam with 100% Correct Answers 2023. What medical term describes the surgical removal of the gallbladder? - Correct answercholecystectomy What does "PHI" stand for? Expand the abbreviation. - Correct answer-Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - Correct answer-False ** A patient underwent brain surgery to treat bleeding in the brain from a stro...

Indiana CNA Skills/RCPs -- 72 SKILLS Questions and Answers 2023 Initial Steps 1. Ask nurse about residents NEEDS, ABILITIES and LIMITATIONS, if necessary. 2. KNOCK and IDENTIFY YOURSELF before entering residents room. WAIT for permission to enter residents room. 3. Greet resident by NAME per resident preference. 4.Identify yourself by NAME and TITLE. 5. Explain what you will be doing. Encourage resident to help as able. 6. Gather supplies and check equipment. 7. Close curtains, drapes an...

A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. ...

NR606 Midterm Exam Questions and Answers Latest 2024/2025 | 100% Correct Answers. Before modifying a care plan to meet a patient's changing needs, the nurse'sfirst action should be to: A. re-do the entire care plan B. focus only on the nursing diagnoses with moderate priority C. assess/reassess the patient's responses to interventions D. add more nursing interventions from a standardized plan of care: C. assess/reassess the patient's responses to interventions 2. True or False: Actual o...

SLPA NC BOARD EXAM MOCK QUESTIONS & answers 2023 verifiedWhat are the 5 Objectives of Intervention? - correct answer 1. Client should ahow improvement not just in a clincial setting; Progress should be generalized to real-world environments. 2. Should be automatic 3. Should be self-monitered 4. Shoul make optimum progress in minimum amount of time 5. Interventionshould be sensitive to personal and cultural characteristics. What is a treatment protocol? - correct answer Written guideline t...

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...

Subjective data --> what the patient says Objective data --> what you observe, such as VS, lab results, and physical assessment findings Assessment --> interpret the subjective and objective data and state the problem or note client progress on the problem (may be in the form of a nursing diagnosis) -Plan --> plan of care to address the problem Correct Answer-What is SOAP charting? Format: (Prohibited abbreviation ) = (Correct term) -U = unit -IU = International Unit -Q.D...

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of 2.6 mEq/L Blood pressure of 120/64 to 130/72 mm HgSodium level of 142 mEq/L, - Answer- Serum potassium level of 2.6 mEq/L A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this...

subjective vs objective feeling vs fact pain vs tenderness patients feeling vs physicians assessment benign normal, nothing of concern acute vs chronic new onset vs long standing baseline an individuals normal state of being ausculation listening to sound with a stethoscope palpation act of pressing on an area (by the physician) inpatient admitted to the hospital overnight outpatient seen and sent home the same day chief com...

NR606 Midterm Exam Questions and Answers Latest 2024/2025 | 100% Correct Answers. Before modifying a care plan to meet a patient's changing needs, the nurse'sfirst action should be to: A. re-do the entire care plan B. focus only on the nursing diagnoses with moderate priority C. assess/reassess the patient's responses to interventions D. add more nursing interventions from a standardized plan of care: C. assess/reassess the patient's responses to interventions 2. True or False: Actual o...