Documentation soap note - Study guides, Class notes & Summaries
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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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Mock CCA Exam Questions & Answers Graded A+ | 2024
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Mock CCA Exam Questions & Answers 
Graded A+ | 2024 
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 p...
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Advanced Health Assessment Quizzes 1-4 Questions & Correct Answers/ Graded A+
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When writing a SOAP note, the nurse practitioner is aware that "A" represents 
: The diagnosis 
When reading a healthcare record you see the following notation: Patient states "I have had a runny 
nose and a cough for 1 week now" This is an example of: 
: Chief complaint 
Which of the following is an appropriate recording of the subjective information provided by a 
patient? 
: "grabbing" chest pain for 2 hours 
You receive results from the laboratory, a metabolic panel and a CBC. Where ...
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NR 599 /NR 599 Midterm Exam ..Nursing Informatics for Advanced Practice NR 511 WEEK 1 :QUIZ 1 The phrase usual and customary refersto: The success rate of a specified procedure. How much an insurer will charge to provide coverage. Correct Answer How charg
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NR 599 /NR 599 Midterm Exam 
..Nursing Informatics for Advanced 
Practice 
NR 511 WNR 599 /NR 599 Midterm Exam 
..Nursing Informatics for Advanced 
Practice 
NR 511 WEEK 1 :QUIZ 1 
The phrase usual and customary refersto: 
The success rate of a specified procedure. 
How much an insurer will charge to provide coverage. 
Correct Answer 
How charges for a service compares with charges made to other personsreceiving similar services and 
supplies. 
How an insurer evaluatesthe need for an ordered dia...
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PTHA 1409 Exam 2 || A+ Graded Already.
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Identify the principles of documentation according to the text and slides. correct answers Accuracy: true; objective; correct spelling and grammar. 
Brevity: concise and to the point; give enough information so as to leave no doubt; abbreviations may help with brevity; use short concise sentences. 
Clarity: meaning is immediately clear to the reader; do not shift tenses; handwriting is legible. 
 
Identify the content of the problem-oriented medical record. correct answers Database: current and ...
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NR 511 Week 1 Quiz (All Correct)
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Week 1: Quiz Attempt History Attempt Time Score LATEST Attempt 1 14 minutes 15 out of 15 Which of the following statements about Medicaid is true? Medicaid pays for family planning serv ices, dental care, and eyeglasses. Eligibility requirements for Medicaid are mandated by the Health Care Financing Administration. Medicaid is a federal plan created to provide care for indigent persons. Medicaid is a program for the indigent financed jointly by the federal and state governments. Financed jointly...
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NHM 365 exam 1 (modules 1-3). Questions and answers, rated A+ / 2024-25 Exam board exam predictions. APPROVED/
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NHM 365 exam 1 (modules 1-3). 
Questions and answers, rated A+ 
what are the 4 steps to the nutrition care process? 
1. assessment 
2. diagnosis 
3. intervention 
4. monitoring and evaluation 
in most cases, who does nutritional screening? 
usually RN or DTR, not RD. usually built into the assessment worksheet nurses use 
Brainpower 
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Previous 
Play 
Next 
Rewind 10 seconds 
Move forward 10 seconds 
Unmute 
0:02 
/ 
0:15 
Full screen 
contents of a SOAP note 
subjective 
objective 
as...
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NUFT 204 Exam Questions and Answers Latest Updated 2024/2025 (100% Solved)
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NUFT 204 Exam Questions and Answers Latest Updated 2024/2025 (100% Solved) Current health or history of current illness - HPI (history of present illness 
4.Past health 
5.Family history 
6.Review of systems - Head to toe 
7.Functional assessment or ADLs " 
Examples of Biographical data in health hstory - ANSWER "Name 
•Address and phone number 
•Age and birth date 
•Birthplace 
•Sex 
•Marital status 
•Race 
•Ethnic origin 
•Occupation—usual and present 
•Source of informa...
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USA PTP 1 FINAL EXAM WITH COMPLETE SOLUTIONS
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USA PTP 1 FINAL EXAM WITH 
COMPLETE SOLUTIONS 
Environmental issues - Answer ️️ -Contextual factors in the ICF enablement model are 
concerned with: 
Providing interpreter services - Answer ️️ -Which of the following terms BEST describes 
cultural competence in physical therapy? 
Fines, Imprisonment, License Revocation - Answer ️️ -HIPAA violations may result in: 
Assessment - Answer ️️ -Which of the following components of the Patient/Client 
Management format does the clinical ...
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Shadow Health Advanced Health Assessment Student Handbook
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Advanced Health Assessment 
 
 
 
 
 
 
 
 
 
 
 
 
Advanced Health Assessment Student Handbook 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
- 1 - 
 
AHAV.1 
 
 
 
 
Advanced Health Assessment 
 
 
 
Health History	. - 4 - 
Example SOAP note Documentation ........................................................................................................... - 6 - 
Self-Reflection ...........................................................................................................
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