Heent exam 1 part 1 - Study guides, Class notes & Summaries

What is important to note in a pt's medical record? -Orders section -Admission note/history and physical (H&P) -Progress notes -Reports What is under the Orders section? -Meds that may affect tx -Activity orders- request if not there -Positioning restrictions -Exams ordered -Laboratory values 00:51 01:13 What is under the subjective portion of a pt's history? -History of present illness -Medical/surgical history, risk factors, allergies -Occupation, lifestyl...

Which of the following medications are prescribed to cancer patients to eradicate the cancer or for prophylaxis? I. Tamoxifen II. Anastrozole III. Januvia IV. Crestor I and II The definition of a best medical record for a RADV audit is: A. Documentation validates the CMS requested HCCs, contains all the necessary documentation elements and has an additional HCC not requested by CMS B. Documentation that validates all the requested HCCs C. Documentation that validates the requested...

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...

Medical Terminology Exam Chapters 1-5 -logist - ANS One who studies; specialist -logy - ANS Study or science of -er, -ist - ANS One who -iatrician - ANS Practitioner -iatrics, iatry - ANS Medical profession or treatment -ac, -al, -ic - ANS Pertaining to -logic, -logical - ANS Pertaining to the study of Cardi(o) - ANS Heart Crin(o) - ANS To secrete; endo-means inside -crine - ANS To secrete Dermat(o) - ANS Skin Gastr(o) - ANS Stoma...

1. Define diagnostic reasoning Reflective thinking because thhe process involves questioning one's thinking to determine if all possible avenues have been explored & if thhe conclusions that are bein g drawn are based on evidence. Seen as a kind of critical thinking. 2. What is subjective data? Anything thhe patient tells you or complains of regarding thheir symptoms Chief complaint HPI ROS 3. What is objective data? Anything YOU can see, touch, feel, hear, or smell as part of your exam Include...

Cathy, 48 F CC: Difficulty breathing with exercise HPI: Cathy is a 48year old female who comes in to the clinic with complains of increased difficulty breathing with exercise. She reports an onset of about 2 weeks ago after recovering from a spring cold. She reports breathlessness that requires her to use 2 puffs of albuterol before running, without effect. She admits to low endurance and energy making it difficult for her to run her usual 5mile run. Cathy denies any chest tightness ...

NURS 6531 Midterm Exam Review (Week 1-6) **Save for Final comprehensive Exam Review** Competencies of Advanced Nurse Practitioners  How to apply advanced practice nursing competencies to clinical settings Upon completion of a nurse practitioner program, nine core competencies were defined as the foundational components instilled in the graduate regardless of the areas of specialty. These competencies consist of: 1. Scientific foundation These competencies ensure that nurse practitioner...

NURS 550 Midterm Exam Questions With Verified Answers Differential Diagnosis - answer• In deciding which disease to include in the differential, consider: - What's the most life-threatening disease the patient could have? - Could this be a common disease presenting with unusual features? - What diseases present with misleading symptoms? - What rare diseases could be causing these signs and symptoms? Develop a Complete, Framed Differential Diagnosis (Hypothesis) - answer• Not all diag...

Focused Exam End of Life (Part 3 of 3) Regina Walker ED Nursing NoteChief Complaint - correct answer Ms. Walker has severe pain related to Stage IV breast cancer mets to bone and liver. Orientation - correct answer Alert and Oriented x 4 History of Present Illness - correct answer Ms. Walker is a 69-year-old African American woman with a history of Stage IV breast cancer with metastases to the bone and liver. Additional history positive for HTN diagnosed at 44. Ms. Walker present to the...

The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose. The minimum necessary standard does not apply to the following: - ANSWER-- Disclosures to or requests by a health care provider for treatment purposes. - Disclosures to the individual who is the subject of the information. - Uses or disclosures made pursuant to an individual'...