Documentation soap note - Study guides, Class notes & Summaries
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Exam 1: NSG121/ NSG 121 (NEW 2024/ 2025 Update) Health Assessment | Review with Questions and Verified Answers| 100% Correct| Graded A- Herzing
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Exam 1: NSG121/ NSG 121 (NEW 2024/ 2025 
Update) Health Assessment | Review with 
Questions and Verified Answers| 100% 
Correct| Graded A- Herzing 
 
QUESTION 
 When percussing a client and you hear a dull sound , where might you be ? 
 
 
Answer: 
Over an organ (heart, liver, spleen) 
 
 
 
QUESTION 
 If you hear a flat sound where might you be? 
 
 
Answer: 
Over muscles, bone, or tumor 
 
 
 
QUESTION 
 If you hear a tympany sound where might you be? 
 
 
Answer: 
Over air pockets (sto...
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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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NSG 526 Exam 1 Question and answers 100% correct
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NSG 526 Exam 1 Question and answers 100% correct NSG 526: Exam 1 
 
 
DSM-5 TR: How is it utilized? - correct answer Utilized in diagnostic assessment process only, 
 
DSM-5 TR: What does it not suggest? - correct answer Treatment strategy. 
 
Accurate Documentation: Why is it significant? - correct answer Significant for legal protection, regulatory standards compliance, reimbursement, liability reduction, consistency in therapeutic intervention, and assistance with utilization review. 
 
Jo...
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NR 565 Week 6 Asthma Case Study Q&A.
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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’...
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NSG6020 Final Exam |100 questions and answers
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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...
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LD 34 EMS Law Enforcement exam fully solved 2024-2025(download to pass)100% accurate
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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...
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Indiana CNA Skills/RCPs -- 72 SKILLS Questions and Answers 2023
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Indiana CNA Skills/RCPs -- 72 SKILLS Questions and Answers 2023 
Initial Steps 
1. Ask nurse about residents NEEDS, ABILITIES and LIMITATIONS, if necessary. 
2. KNOCK and IDENTIFY YOURSELF before entering residents room. WAIT for permission to enter residents room. 
3. Greet resident by NAME per resident preference. 
4.Identify yourself by NAME and TITLE. 
5. Explain what you will be doing. Encourage resident to help as able. 
6. Gather supplies and check equipment. 
7. Close curtains, drapes an...
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Exam 2: PNR 104 / PNR104 (Latest 2024/ 2025 Update) Basic Skills, Quality & Safety in Nursing Practice Review| Questions and Verified Answers| 100% Correct- Grade A- Fortis
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Exam 2: PNR 104 / PNR104 (Latest 2024/ 2025 Update) Basic Skills, Quality & Safety in Nursing Practice Review| Questions and Verified Answers| 100% Correct- Grade A- Fortis 
 
 
Q: 6 main methods of documentation 
 
 
Answer: 
source-oriented (narrative) charing, problem oriented medical record charting (POMR) focus charting, charting by exception, computer assisted charting, and case management system charting. 
 
 
 
Q: source oriented charting (narrative) 
 
 
Answer: 
narrative notes are phr...
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FIPP 5 Exam #1 Questions with Correct Answers
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PURPOSES OF DOCUMENTATION Correct Answer-• Improving patient care & outcomes.• Providing patients with information about their care.• Enhancing continuity of care.• Ensuring compliance with laws & regulations.• Protecting against professional liability.• Creating a record of services provided for billing & reimbursement purposes. • Establishing the pharmacist's credibility as a health care provider. 
 
SOAP Note stands for: Correct Answer-subjective, objective, assessment, plan 
 ...
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SOAP NOTE DOCUMENTATION FINAL EXAM 2024.
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SOAP NOTE DOCUMENTATION FINAL EXAM 2024. 
Outline - ANSWER Title, date, time 
S: CC, HPI 
O: Vitals, PE, labs/imaging/procedures 
A: 1. working diagnosis and tests to rule out ddx, 2. 3. 4. 
P: Disposition, diagnostics, treatment, follow up 1. 2. 3. 4. 
 
General ROS - ANSWER weakness 
chills 
fever 
night sweats 
fatigue 
weight changes 
 
skin ROS - ANSWER rashes 
lesions 
abnormal hair loss 
abnormal nail growth 
edema 
changes in color/texture 
diaphoresis 
pruritus 
 
head ROS - ANSWER...
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Mock CCA Exam Questions & Answers Graded A+ | 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 recreated 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's initial assessment of the patient. You can e...
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