Writing soap notes Study guides, Class notes & Summaries

GUIDE TO Clinical Documentation Debra D. Sullivan, PhD, RN, PA-C Lead Advanced Practice Provider Academic Urology and Urogynecology of Arizona Litchfield Park, AZ Owner, Sullivan Consulting Services Medicolegal Consulting Glendale, AZF. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 Copyright © 2019 by F. A. Davis Company Copyright © 2019 by F. A. Davis Company. All rights reserved. Łis product is protected by copyright. No part of it may be reproduced, stored in a r...

HESI RN LEADERSHIP QUESTIONS & ANSWERS 2023/2024 UPDATE HESI RN LEADERSHIP 2023 UPDATE 1. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be inserted. b. Document the client’s refusal in the chart. c. Assess the client for uri...

Complete 2024, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required fo...

1. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? A. Inform the transferring agency of the client's condition. B. Privately interview the client about her condition. C. Notify risk management D. Contact the family regarding the client's condition. - B. Privately interv...

Writing SOAP Notes

Writing SOAP Notes

Writing SOAP Notes

Questions You Might Have About the Examination The practice of nursing is regulated by the states to assure the public that only those nurses who have the necessary knowledge and skills are licensed to practice. One requirement for becoming a licensed practical/vocational nurse (LPN/LVN) is graduation from an approved school of practical/vocational nursing. Another requirement is passing an examination. All of the states have agreed to use the same ®® examination, NCLEX-PN . The NCLEX-PN is...

CDA EXAM LATEST 2023 REAL EXAM 150 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) GRADED A Ms. Hart walks toddlers through the neighborhood several times a week. Which strategy makes for the best learning experience? A: Telling the children about how the neighborhoods has changed over time. B: Permitting the children to pick any flowers or leaves they encounter. C: Taking one path often enough to observe and talk about what is there. D: Taking a diff...

Infection Control Exam Questions and Answers Already Passed A copy of which of the following must be included in an OSHA-mandated training program? A. Handout materials B. Dental office employee handbook C. Bloodborne Pathogens Standard D. Environmental Protection Agency Standard C Which of the following describes a housekeeping surface? A. Instrument tray B. Operatory wall C. Examination light D. Operatory drawer handle B What hand hygiene technique is necessary after removi...

Fundamentals CMS Midterm Terms in this set (200) A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high- pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub A nurse is obtaining ...