Writing soap notes Study guides, Class notes & Summaries

HESI Comprehensive Exit Exam Questions and Answers graded A+ SEP 2023/24 HESI Comprehensive Exit Exam questions and answers graded A+ 100% 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...

What is the name of the process for maintaining order in files by separating active from inactive files? Purging Purging As information accumulates, it is necessary to maintain files by the process known as purging. This requires sorting through records and removing those not in active use. Brainpower Read More What is the name of the system used as a reminder of action to be taken on a certain date? Tickler file Tickler file A well-organized, efficient clinic will m...

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 documentation is only accepted in court if written by hand. ANS: A Accurate documentation is necessary for hospitals to be reimbursed...

CCA Exam Questions and Answers 100% Verified What does the acronym PHI stand for? Protected Health Information Which of the following statements regarding healthcare provisions of Medicare are False? Medicare is federally and state funded A patient consent to potentially assume financial responsibility for a service or procedure that may be denied by Medicare. What form must the patient fill out. ABN A 31 year old female undergoes surgery for a bilateral salpingectomy. Based on your knowledge...

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 - Answer health care providers prescribed plan of action POMR Note Charting - An...

BOC Practice Test questions and answers latest 2023Which of the following is an example of a closed chain exercise in the upper extremity? Choose only one. a. Push-up b. Military press c. Codman's pendulum d. Bicep curl e. Bench press a. push-up What are the appropriate procedures to follow when cleaning BBP from wrestling mats? Choose all that apply. a. Spray contaminated area with alcohol b. Spray contaminated area with 1:10 ratio bleach solution c. Spray area with alcohol and...

Newborn At Risk NCLEX Exam 55 Questions with Verified Answers The pediatric nurse prepares a newborn for phototherapy. The nurse explains to the parents that certain organs need to be protected during treatment. Which organs are these? A. Eyes and ears B. Eyes and hands C. Eyes and genitals D. Genitals and hands - CORRECT ANSWER C ~ Phototherapy uses daylight and cool white, blue, or special blue fluorescent light tubes. These lights are the most effective form of phototherapy and are pla...

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....

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...

NURS 231 Exam 3 Questions With Verified Answers Graded A+ 2024/2025 - accurate, up to date information - collaborative - privacy - improve productivity - reducing cost - research Electronic Health Records - "mistaken entry" date and initial - "mistaken entry - wrong chart" and sign off - delete part of the permanent record - type explanation into computer with date, time, and initials and submit explanation in writing to manager correcting errors - paper format in which ...