When writing a soap note Study guides, Class notes & Summaries

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...

What does "PHI" stand for? Expand the abbreviation - protected health information What medical term describes the surgical removal of the gallbladder? - cholecystectomy T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case - False A patient's PCP is on vacation. The patient is scheduling to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP before. Is the patient co...

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 ...

Principles of Athletic Training: Athletic Injuries Ch.9 & 10 Exam || All Questions & 100% Correct Answers (A+) Principles of Athletic Training: Athletic Injuries Ch.9 & 10 Exam || All Questions & 100% Correct Answers (A+) What bone is most likely to sustain a depressed fracture? - ANSWER - Parietal What is one of the most common overuse problems associated with activity? - ANSWER - Tendinitis Which muscular injury is characterized by an extremely painful involuntary muscle contraction ...

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 sho...

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...

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 s...

Components of the EMS System - DISPATCHER: Coordinates type and level of EMS response and dispatches the appropriate agencies. An emergency medical dispatcher may give medical instructions to the public. - FIRST RESPONDER: Entry level medically trained person. - EMT: Provides basic life support/BLS. - PARAMEDIC: Provides advanced life support/ALS. - RECEIVING FACILITY: The medical treatment facility that provides emergency care. Primary Responsibilities As first responders, peace of...

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 should th...