Writing soap notes - Study guides, Class notes & Summaries

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 ...

RN ATI Fundamentals (10.0) Chapter 1 1. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Sele ct all that apply.) a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities e. Oncology centers 2. A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms ...

NU 131 - Test 1 - Chapters 4, 14, 1, 5, and 12 with100% Correct Answers Founded in ___________ by the Lutheran Order of Deaconesses - Answer- 1836 in Kaiserswerth, Germany Most popular student was _______________________ - Answer- Florence Nightingale Florence Nightingale became a superintendent of the Institution for the Care of Sick Gentlewomen in Distressed Circumstances and renamed it the ________________________________ - Answer- Harley Street Nursing Home Florence Nightingale insta...

What does the S in SOAP stand for - correct answer Subjective: Describes the patients condition in a narrative form. How they describe what they're feeling What does the O in SOAP stand for - correct answer Objective: Documents and traceable facts about the patients status What does A in SOAP stand for - correct answer Assessment: the physicians medi...

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...

What is a SOAP note? - correct answer A common documentation style used by healthcare providers that's written to outline and manage drug related problems What does SOAP stand for? - correct answer Subjective Objective Assessment Plan What does FARM stand for? - correct answer Findings (S/O) Assessment Recommendations Monitoring What does DA...

What is a SOAP Note? - correct answer Commonly utilized format for documentation in patient medical record Components of SOAP Note - correct answer S - Subjective O - Objective A - Assessment P - Plan What are the 3 steps in writing a SOAP note? - correct answer 1. Collect patient data 2. Analyze available information 3. Formulate an assessment ...

NU 131 - Test 1 - Chapters 4, 14, 1, 5, and 12 Questions With Correct Answers Founded in ___________ by the Lutheran Order of Deaconesses - ANSWER 1836 in Kaiserswerth, Germany Most popular student was _______________________ - ANSWER Florence Nightingale Florence Nightingale became a superintendent of the Institution for the Care of Sick Gentlewomen in Distressed Circumstances and renamed it the ________________________________ - ANSWER Harley Street Nursing Home ...

What are four things good case notes do? - correct answer Represent the client's situation; provide a record of client care; enable an action to be taken based on their review; and can be used in court, in school, by social agencies, and by insurance companies To whom is documentation critical? - correct answer Clients and family members; health care providers; employers and managed care companies; and licensing and accredit...

HESI Community Test Bank 2022 1000+ Questions and Answers Updated, A+ Guide. 1. During a two-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: temperature 101.8°F, blood pressure 100/50, heart rate 104 beats/minute, and respirations 18 breaths/minute. Which action should the nurse take? a. Determine the client's current oxygen saturation rate. b. Inst...