A soap note follows - Study guides, Class notes & Summaries

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...

subjective vs objective feeling vs fact pain vs tenderness patients feeling vs physicians assessment benign normal, nothing of concern acute vs chronic new onset vs long standing baseline an individuals normal state of being ausculation listening to sound with a stethoscope palpation act of pressing on an area (by the physician) inpatient admitted to the hospital overnight outpatient seen and sent home the same day chief com...

Acute vs Chronic correct answers new onset, to be of concern vs. long standing, not as concerning Seen and sent home the same day correct answers outpatient Chief complaint is... correct answers the main reason for the patient's visit A set of government mandated criteria that must be obtained for every patient correct answers meaningful use Baseline correct answers An individual's normal state of being Tasks you CAN complete as a scribe correct answers - document the history an...

SOAP Correct Answer subjective, objective, assessment, plan Subjective Correct Answer based on the patient's feeling (HPI and ROS) Objective Correct Answer Factual information from provider (PE) History of Present Illness (1 simple def) Correct Answer The story of the patient's chief complaint Review of Systems Correct Answer Head to toe checklist of patient's symptoms Intermittent Correct Answer comes and goes Waxing and waning Correct Answer always present but changing ...

NSG 526: Exam 1 question n answers graded A+ 2024/2025DSM-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. Joint Commission o...

A SOAP note follows ___________________________________ so that each portion of the SOAP note is documented consecutively as information is obtained from the patient. - ANSWER the workflow of the clinic Review: Define SOAP (expand acronym) - ANSWER Subjective, Objective, Assessment, (and) Plan Review: Define Subjective. What does it include (3)? - ANSWER Information from the patient. 1. Chief complaint 2. HPI 3. ROS

SOAP Correct Answer subjective, objective, assessment, plan Subjective Correct Answer based on the patient's feeling (HPI and ROS) Objective Correct Answer Factual information from provider (PE) History of Present Illness (1 simple def) Correct Answer The story of the patient's chief complaint Review of Systems Correct Answer Head to toe checklist of patient's symptoms Intermittent Correct Answer comes and goes Waxing and waning Correct Answer always present but changing ...

Acute vs Chronic Correct Answer new onset, to be of concern vs. long standing, not as concerning Seen and sent home the same day Correct Answer outpatient Chief complaint is... Correct Answer the main reason for the patient's visit A set of government mandated criteria that must be obtained for every patient Correct Answer meaningful use Baseline Correct Answer An individual's normal state of being Tasks you CAN complete as a scribe Correct Answer - document the history and phys...

A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of 2.6 mEq/L Blood pressure of 120/64 to 130/72 mm HgSodium level of 142 mEq/L, - Answer- Serum potassium level of 2.6 mEq/L A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this...

ScribeAmerica OP Course 1, 2, 3 Exam Questions & Answers 2023/2024 SOAP - ANSWER-Subjective, Objective, Assessment, Plan Subjective - ANSWER-Based on the patient's feeling (HPI,ROS) objective - ANSWER-Factual information from provider (PE) History of Present Illness - ANSWER-The story of the patient's chief complaint Review of Systems - ANSWER-Head-to-toe checklist of patient's symptoms Intermittent - ANSWER-comes and goes waxing and waning - ANSWER-always present but c...