Emr soap note - Study guides, Class notes & Summaries

S.O.A.P note - correct answer Subjective Objective Assessment Plan Subjective - correct answer -This section is reported by the patient. -It is important to specify who is providing the information (patient, guardian, a nurse, etc.) -Pediatric patients must always have an adult present to speak on their behalf. -You must also consider if the source of information is reliable. If the person giving ...

What are the 5 steps of Pharmacists' Patient Care Process (PPCP) correct answers 1. Collect 2. Assess 3. Plan 4. Implement 5. Follow-Up How are SOAP and PPCP correlated? correct answers Collect = S & O (subjective and objective) Assess = A Plan + Implement + Follow-Up = P Subjective vs. Objective information correct answers Subjective - from the patient Objective - from clinician, the EMR, pharmacy records, etc. (not from patient) Assessment vs. Plan correct answers Assessment...

CRC final exam study guide questions format with solutions 100% correct What is the collection of written or graphic information documenting the facts and events during the rendering of patient care? Health record (or Medical Record) What are the four sections of a SOAP office visit note? Subjective, Objective, Assessment, Plan What is an electronic file wherein patients health information from a single medical provider is stored in a computer system? EMR What does EMR stand for? Elec...

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

SCRIBE AMERICA FINAL EXAM REVIEW QUESTIONS AND ANSWERS, RATED A+/ What does PHI stand for (abbreviation) protected health information What medical term describes the surgical remval of the gallblader cholecystectomy T/F Sharing information about a case with family is allowed as long as you are scribing with the physician asssigned to the case False A patient's PCP is on vacation. The patient is scheduled to see the NP who is covering for the PCP during this time. The patient has ne...

What does "PHI" stand for? Expand the abbreviation - protected health information What medical term describes the surgical removal of the gallbladder? - cholecystectomy 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's PCP is on vacation. The patient is scheduling to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP before. Is the patient co...

Nursing Informatics Exam 229 Questions with Verified Answers Information theory - CORRECT ANSWER Processing data to produce information and, in combination with knowledge and wisdom, using information to provide care Change Theory - CORRECT ANSWER unfreezing -->moving-->refreezing Systems Theory - CORRECT ANSWER interaction among parts Behaviorism - CORRECT ANSWER desired behaviors are reinforced Constructivism - CORRECT ANSWER reinterpret the world to fit new situations ...

* What medical term describes the surgical removal of the gallbladder? - Answer cholecystectomy What does "PHI" stand for? Expand the abbreviation. - 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. - Answer False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Answer craniotomy A patien...

EMT-B Midterm Chapters 1-23 Questions & Answers. An EMS provider who has extensive training in various aspects of advanced life support (ALS) is called: A. paramedic. B. advanced EMT (AEMT). C. EMT. D. EMR. If a defibrillator manufacturer claims that its device terminates ventricular fibrillation on the first shock 95% of the time, you should: A. avoid purchasing the device because this claim is unrealistic. B. recognize that this does not mean it will save more lives. C. purcha...

RHIT FINAL EXAM PRACTICE QUESTIONS WITH COMPLETE SOLUTION 2023/2024 100% CORRECT. The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an) AMA-approved product Certified EHR Joint Commission-approved system Functional EMR - Answer Certified EHR In prepar...