Documentation soap note - Study guides, Class notes & Summaries
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Intro to PT 1409 Unit II Exam || with 100% Verified Solutions.
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3 Essentials Principles of Documentation correct answers Accuracy -Avoid General Statements, be complete with your statements 
Brevity - Concise and to the point, give info to leave no doubt 
Clarity - Immediately clear to reader. HW is legible. 
 
SOAP Note was introduced in the ______ by Dr. _______, dubbed a ______ correct answers 60s, Lawrence Reed, POMR. 
 
Content of the POMR correct answers Database (current and past information about the patient) 
Problem List (Problems to be treated) 
I...
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NR 511 Week 1 Clinical Readiness Exam – Questions And Answers
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NR 511 Week 1 Clinical Readiness Exam – Questions And Answers 
Define diagnostic reasoning 
What is subjective data? 
What is objective data? 
Components of HPI 
Why must every procedure code have a corresponding diagnosis code? 
What are the three components required in determining an outpatient office visit E&M code? 
What is medical coding? 
… medical billing? 
What are CPT codes? 
—- ICD codes? 
What is specificity? 
…… sensitivity? 
What is predictive value? 
… elements need to ...
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Documentation "SOAP" Note Prep Exam Questions And Answers All Correct/2024.
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What are 4 reasons documentation is important? - correct answer 1. Continuity of pt care 
2. Reimbursement 
3. Research and Education 
4. Liability 
 
Which of the following is not an audience for your documentation. 
 
A) Yourself 
B) The patient 
C) Physician/ other medical team members 
D) Payers 
E) Quality assurance review 
F) Research 
G) All are correct - correct answer G) All are correct 
 
Befo...
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Mock CCA Exam questions and answers 2024
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Your organization is sending confidential patient information across the Internet using technology that will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called 
a. firewall 
c. a call-back process 
b. validity processing 
d. data encryption - ANSWER-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. ...
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NHA CEHRS Final Exam Questions and Answers
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NHA CEHRS Final Exam Questions and Answers 
What code category does a provider used to report encounters based on level of service 
A. Practice management codes 
B. Evaluation and management codes 
C. State regulated insurance codes 
D. Quality improvement codes - Answer-B. Evaluation and management codes 
 
A federal organization request patient data to conduct a research study. What action should the EHR specialist take 
A. Transfer patient data 
B. Remove PHI from the patient data 
C. Contact...
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Mock CCA Exam Questions and Answers Already Passed
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Mock CCA Exam Questions and Answers Already Passed 
Your organization is sending confidential patient information across the Internet using technology that will transform the original data into unintelligible code that can be re-created 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...
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NCLEX HEALTH PROMOTION AND MAINTENANCE EXAM 2024
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NCLEX HEALTH PROMOTION AND MAINTENANCE EXAM 2024 
 
 
The nurse is providing instructions to the mother of a child with human immunodeficiency virus infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule? - correct answer "Family members in the household need to receive the influenza vaccine." 
 
The nurse is preparing to provide instructions to a new mother regarding cord care for a newborn infant. Which instructions would the...
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Advanced Physical Assessment Midterm
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Advanced Physical Assessment Midterm 
list and describe general guidelines for recording information r/t health hx documentation 
organize, synthesize, record the data, record problems, record plan. take brief notes during exam, 
document full recording asap, dont use abbreviations, write what the pt tells you, not what you 
perceive. record expected/unexpected findings. 
what is a soap note? 
commonly used process to organize pt data obtained during the exam 
what are the components of a soap...
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SLPA Final Exam Questions and Answers 100% Pass
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SLPA Final Exam Questions and Answers 100% Pass CLINICAL DOCUMENTATION The record of clinical observations and care a patient receives 
During data collection, choose the following duties that are within the scope of practice for the SLPA prepare charts or graphs regarding treatment data tally or record specific behaviors presented during tx 
what documentation items are within the scope of practice to be completed by the SLPA? Lesson Plans, SOAP Notes/Data Logs, Progress Reports 
When collectin...
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PNR 104 Exam 2 (Answered) Verified Solution
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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.)...
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