Patient chief complaint - Study guides, Class notes & Summaries

Debbie O Connor-COPD Shadow Health Questions and Answers Latest (100% VERIFIED) History of Present Illness • Finding: Asked about additional symptoms • Finding: Reports fatigue and weakness (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the a...

DD Form 689 Individual sick call slip that initiates the sick call process Used for patient who requests or receives medical/dental evaluation or treatment at an Army Medical Treatment Facility (MTF) used as a means of communication between medical personnel and the patient's commander SF 600 Chronological Record of Medical Care form used to document the chronological record of the patient's treatment Should include: - Date and time of visit - Medical Treatment Facilit...

what is the primary function of a medical scribe? - create the medical note what is the preferred format for the creation of the medical note? - subjective, objective, assessment, plan (soap) "present time" pt details are summarized by using what format - OPQRST all current procedural terminology (CPT) codes must be justified by what appropiate coding mechanisms - international classification of disease (ICD) what patient history is outlined in the PMHx - medical history what scribing i...

Cardiology FISDAP practice quiz when obtaining a 12 - lead ECG, lead V1 should be placed: A) upper right shoulder just above the clavicle B) approximately 1 inch to the right of the angle of Louis C) In the sec intercostal space just inferior to the sec rib. D) in the fourth intercostal space just to the right of the sternum - ANSWER D) in the fourth intercostal space just to the right of the sternum A patient experiencing a right ventricular infarct...

JIBC PARA 1250 | 120 Questions with 100% Correct Answers | Latest Update | Verified Elements of paramedic practice - Identify problems. Set patient care priorities. Develop a prehospital care plan. Execute the plan. Evaluating overall scene safety and stability is the ______________ step of responding to an emergency call. - first On most calls, the two most important pieces of patient history information that you need to obtain are - the patient's name and chief complaint Pulling toget...

HEALTH ASSESSMENT HESI VERSION 2 EXAM COMPLETE GUIDE QUESTIONS WITH VERIFIED ANSWERS 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 dur...

Medical Billing and Coding Certificate Exam Already Passed Chief Complaint (element 1 of history) History of present illness, Review symptom, Past, Family, and Social history History Levels (Element 2 of history) and Examination Levels (Element 3 of History) Problem focused, expanded problem focused, detailed, Comprehensive Medical Decision Making Complexity Levels (element 4 of history) Straightforward, Low, Moderate, High straightforward Minimal diagnosis Minimal...

• Question 1 Sara is a 38 y/o multipara who is in her 6th–7th month of pregnancy with her fourth child. She has a new onset of vaginal bleeding that is worsened by intercourse. On external physical exam, you note that her uterus is soft and non-tender to palpation. The most likely diagnosis for this condition is: Selected Answer: Placenta previa Answers: Placental abruption Severe preeclampsia Placenta previa None of the above Adela is a 38 y/o overweight female who presents...

City MD Scribe Latest 2024 Already Graded A Phase 1 n y & vitals 3.Past medical History 4.Chief complaint 5.HIP (history of present illness) 6.ROS (review of systems) Rapid strep Sore throat rapid flu flu like symptoms Urine test Urine complaints, abdominal complaints (if female) Visual acuity eye complaints Past medical history (in order) 1. current medication 2.Medical conditions 3.Allergies 4.Surgical history 5. family history 6. social history HPI (in order) Onset severity nature Perti...

National Coverage Determination (NCD) - Which of the following Medicare policies determines if a particular item or service is covered by Medicare? Adjudication - Which of the following is considered the final determination of the issues involving settlement of an insurance claim? Encounter Form - A form that contains charges, DOS, CPT codes, ICD codes, fees and copayment information Admitting clerk - A patient comes to the hospital for an inpatient procedure. Which of the following hospi...