Heent documentation - Study guides, Class notes & Summaries

Define diagnostic reasoning - Reflective thinking because the process involves questioning one's thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Seen as a kind of critical thinking. What is subjective data? - What the patient tells you, complains of, etc. Chief complaint HPI ROS What is objective data? - What YOU can see, hear, or feel as part of your exam. Includes lab data, diagnostic test results. Com...

NRNP 6550: Advanced Care of Adults in Acute Settings II i-Human: Ken Fowler V5 FILL OUT THIS TEMPLET AS YOU GO THROUGH THE I-HUMAN PATIENT MODULE SO YOU KNOW WHAT YOU ARE DOING AS YOU GO. YOU ARE ALL WELCOME!!! Name: Ken Fowler Age: 70 years Sex: M Ht: 5'10" (178.0 cm) Wgt: 190 lb (86.0 kg) (BMI 27.3) NOTES FROM i-HUMAN ASSESSMENT: 1) Observations: warm and sweaty 2) Chief complaint: Nausea and fatigue QUESTIONS: (ask the patient up to 100 questions) 1) How can I help you today? ...

PURPLE BOOK RHIT PRACTICE EXAM 2, RHIT Exam 1 (2023) What data set would be most helpful in developing a hospital trauma data registry? - Answer-DEEDS Treatment plans and instructions are an example of which of the N.H.I.N, national health information system dimensions? - Answer-personal health The hospital's HIM department conducted a random sample of 540 health records to determine the rate of filing accuracy. 13 misfiles were identified. What percentage represents filing accurac...

Advanced Health Assessment – HEENT questions and answers, latest updated, graded A+ Inspect Palpate Percussion Auscultation Function - specific techniques for that area Documentation of area Systematic assessment of HEENT Size Shape Symmetry Position Texture and distribution of hair Head and scalp inspection Head for masses, tenderness Scalp mobility Head and scalp palpation Normocephalic Atraumatic Documentation of the head Review of systems questio...

Focused Exam: Alcohol Abuse (Part 3 of 3) C487 Psych/Mental Health Clinical - Aug 2018, C487 Return to Assignment Reflections Documentation Review Nursing Admitting... Mental Status Note SBAR Nursing Admitting Note Student Response Model Documentation Chief Complaint right wirst pain following a car accident Ms. Adler has a sprained (R) wrist due to an MVA caused by impaired driving. She is a self- harm risk and expressed passive suicidal ideation. H...

Health assessment test one: Skin, HEENT questions and answers with verified content Three types of assessment 1. emergency: life threatening or unstable (serve them first) 2. comprehensive: complete health history and physical assessment performed, annual physical, or every 8 hours in critical care 3. focused: smaller in scope but more in depth for specific complaints HIPAA -privacy agreement -disclosure and use of patient information Subjective Data -patient is the prim...

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

NR 509 Week 4: Preparing for the Midterm Week 4: Preparing for the Midterm Midterm Study Guide Chapter 1 • Basic and Advanced Interviewing Techniques • Components of the Health History � �� Subjective Data • Objective Data • SOAP Note Documentation Chapter 2 • Evaluating Clinical Evidence • Critical Thinking and Reasoning • Differential Diagnoses • Pathological and Physiological Processes • Problem List • Problem Prioritization Chapter 3 • Interpretation and Analysis ...

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