Soap documentation - Study guides, Class notes & Summaries

NR 565 Week 6 Asthma Case Study Q&A.The Subjective, Objective, Assessment, and Plan (SOAP) note is a method of documentation used by NPs and other healthcare professionals and includes: S: subjective information provided by the patient O: objective information obtained by the provider A: assessment is the medical diagnosis rather than the physical assessment. *Hint, this information has already been provided to you in the case. P: medical plan. Write a brief SOAP note addressing Haley’...

Exam 1: NR 302/ NR302 (Latest 2025/ 2026 Update) Health Assessment I Guide | Questions & Answers| Grade A| 100% Correct (Verified Solutions)- Chamberlain Q: Leaving your phone before conducting a health assessment is and example of what kind of communication skill Answer: Focus Reducing noise Q: Active listening Answer: Paying attention to body language Using facial expressions Ask clarifying questions Q: "It must've been difficult to leave your abusive rel...

The brain and spinal cord are included in which of the following? Central nervous sytsem The cranial nerves 31 pairs of spinal nerves, and branches make up which of the following? Peripheral nervous system A rotational sensation of spinning is considered to be which of the following? Vertigo A sensation of numbness and or tingling of the extremities is referred to as which of the following? Paresthesia Lightly touching the cornea with a cotton ball would be exam...

Nurse Jalen is reviewing the electronic medical record (EMR) and is preparing for Louis's admission. To which of the following rooms should nurse Jalen anticipate Louis being assigned? - answer A private room that has an attached anteroom. Charge nurse Erika and nurse Jalen are preparing to enter the client's room. Which of the following masks should nurse Jalen ensure are available to health care personnel before entering Louis's room? - answer D When reviewing Louis's data in the ele...

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 collecting data to determine a client's progr...

Nursing Documentation & Informatics Questions and Answers Already Passed Which of the following best describes an electronic health record (EHR)? A) A paper-based system for recording patient information B) A digital system used to store, manage, and retrieve patient health information C) A manual record-keeping method used for billing purposes D) A system used only for scheduling patient appointments B) A digital system used to store, manage, and retrieve patient health information ...

HESI Health Assessment EXAM SOAP modified format - CORRECT ANSWER Subjective Objective Assessment Plan What color ink should be used when documenting on paper - CORRECT ANSWER Permanent black ink What is the correct order for vital signs - CORRECT ANSWER T, P, RR, BP, extremity, pt position, SPO2 What should be at the top of every page of documentation - CORRECT ANSWER Patient initials and date and time of entry What should be at the end of every documentation entry - CORRECT ANS...

HESI Health Assessment EXAM SOAP modified format - CORRECT ANSWER Subjective Objective Assessment Plan What color ink should be used when documenting on paper - CORRECT ANSWER Permanent black ink What is the correct order for vital signs - CORRECT ANSWER T, P, RR, BP, extremity, pt position, SPO2 What should be at the top of every page of documentation - CORRECT ANSWER Patient initials and date and time of entry What should be at the end of every documentation entry - CORRECT ANS...

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 ...

NURS 6011 Exam 1 Study Guide Questions with 100% Verified Correct Answers Nurses assess health on many levels, including: - Correct Answer 1. psychosocial 2. physical 3. emotional 4. spiritual 5. cultural Nursing process to care for patients by? - Correct Answer 1. assessing 2. making nursing diagnoses 3. develop outcomes 4. planning for care 5. performing interventions 6. evaluating 7. revising interventions as needed Nursing has a focus comprising four main goals - C...