Documentation soap note - Study guides, Class notes & Summaries

Exam 1: NSG121/ NSG 121 (NEW 2024/ 2025 Update) Health Assessment | Review with Questions and Verified Answers| 100% Correct| Graded A- Herzing QUESTION When percussing a client and you hear a dull sound , where might you be ? Answer: Over an organ (heart, liver, spleen) QUESTION If you hear a flat sound where might you be? Answer: Over muscles, bone, or tumor QUESTION If you hear a tympany sound where might you be? Answer: Over air pockets (sto...

PNR 104 Exam 2 (Answered) Verified Solution 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.) ...

NSG 526 Exam 1 Question and answers 100% correct NSG 526: Exam 1 DSM-5 TR: How is it utilized? - correct answer Utilized in diagnostic assessment process only, DSM-5 TR: What does it not suggest? - correct answer Treatment strategy. Accurate Documentation: Why is it significant? - correct answer Significant for legal protection, regulatory standards compliance, reimbursement, liability reduction, consistency in therapeutic intervention, and assistance with utilization review. Jo...

NR 565 Week 6 Asthma Case Study Q&A.The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by NPs and other healthcare professionals and includes: S: subjective information provided by the patient O: objective information obtained by the provider A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information has already been provided to you in the case. P: medical plan. Write a brief SOAP note addressing Haley’...

The brain and spinal cord are included in which of the following? Central nervous sytsem The cranial nerves 31 pairs of spinal nerves, and branches make up which of the following? Peripheral nervous system A rotational sensation of spinning is considered to be which of the following? Vertigo A sensation of numbness and or tingling of the extremities is referred to as which of the following? Paresthesia Lightly touching the cornea with a cotton ball would be exam...

Components of the EMS System - DISPATCHER: Coordinates type and level of EMS response and dispatches the appropriate agencies. An emergency medical dispatcher may give medical instructions to the public. - FIRST RESPONDER: Entry level medically trained person. - EMT: Provides basic life support/BLS. - PARAMEDIC: Provides advanced life support/ALS. - RECEIVING FACILITY: The medical treatment facility that provides emergency care. Primary Responsibilities As first responders, peace of...

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...

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...

PURPOSES OF DOCUMENTATION Correct Answer-• Improving patient care & outcomes.• Providing patients with information about their care.• Enhancing continuity of care.• Ensuring compliance with laws & regulations.• Protecting against professional liability.• Creating a record of services provided for billing & reimbursement purposes. • Establishing the pharmacist's credibility as a health care provider. SOAP Note stands for: Correct Answer-subjective, objective, assessment, plan ...

SOAP NOTE DOCUMENTATION FINAL EXAM 2024. Outline - ANSWER Title, date, time S: CC, HPI O: Vitals, PE, labs/imaging/procedures A: 1. working diagnosis and tests to rule out ddx, 2. 3. 4. P: Disposition, diagnostics, treatment, follow up 1. 2. 3. 4. General ROS - ANSWER weakness chills fever night sweats fatigue weight changes skin ROS - ANSWER rashes lesions abnormal hair loss abnormal nail growth edema changes in color/texture diaphoresis pruritus head ROS - ANSWER...

Your organization is sending confidential patient information across the Internet using technology that will transform the original data into unintelligible code that can be recreated by authorized users. This technique is called a. firewall c. a call-back process b. validity processing d. data encryption - d. data encryption As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can e...