Soap subjective hpi - Study guides, Class notes & Summaries

NR 606 Midterm Exam Questions and Answers Latest 2024/2025 | 100% Correct Answers. Before modifying a care plan to meet a patient's changing needs, the nurse'sfirst action should be to: A. re-do the entire care plan B. focus only on the nursing diagnoses with moderate priority C. assess/reassess the patient's responses to interventions D. add more nursing interventions from a standardized plan of care: C. assess/reassess the patient's responses to interventions 2. True or False: Actual ...

Before modifying a care plan to meet a patient's changing needs, the nurse's first action should be to: A. re-do the entire care plan B. focus only on the nursing diagnoses with moderate priority C. assess/reassess the patient's responses to interventions D. add more nursing interventions from a standardized plan of care - C. assess/reassess the patient's responses to interventions True or False: Actual or potential health problems that can be prevented or resolved by dependent nursin...

Define diagnostic reasoning - A list of possible diagnoses based on historical and clinical presentation listed in order of priority Identify subjective and objective data - Subjective data is what the patient tells you (SAYS) objective data is what you see: labs, etc. (OBSERVE) Identify the components of the HPI - OLDCARTS onset location duration characteristics aggravating factors relieving factors timing and severity Develop an appropriate differential: - Confirm or rule out...

HCB 102 SOAP Notes Question and answers correctly solved HCB 102 SOAP Notes Subjective - correct answer The initial portion of the soap note, consists of subjective observations. these are symptoms verbally given to the HM by the patient or by a significant other Objective - correct answer Objective observations include signs the HM can actually see, hear, touch, feel, or smell Assessment - correct answer Assessment is the preliminary diagnosis of patients condition Plan - co...

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...

Chief Complaint - Answer-the main reason for the pt's ED visit pain vs tenderness - Answer-pt's feelings (subjective) vs physician's assessment (objective) distress - Answer-the doctor's judgement of discomfort baseline - Answer-an individual's normal state of being What CAN scribes do? - Answer--Document Hx, PE, results, procedures, and physician consults -Access and document lab results and radiology findings -Locate and obtains PMHx, previous charts, past results, and recent studie...

T/F: The structure of the SOAP note closely follows the clinic flow. - ANSWER True T/F: You will usually document the assessment before documenting the HPI. - ANSWER False What are two components of the subjective assessment? - ANSWER HPI and ROS Which portion of the SOAP note contains the results of orders? - ANSWER Objective

SOAP - correct answer subjective, objective, assessment, plan Examples of subjective data - correct answer HPI, ROS, PHx (medical, surgical, social, family Examples of objective data - correct answer Physical exams, orders and results Chief Complaint - correct answer The main reason for the patient's visit EMR/EHR - correct answer Electronic Medical Record/Electronic Health Record Subjective - correct answer Feeling Objective - correct answer Factual information from pr...

Health History SOAP SUBJECTIVE: ID: J.M, age 10, Caucasian female, DOB 01/14/12011. The patient is accompanied by her mother and the patient and mother are reliable historians. Patient presents to the clinic for a wellness check and no current concerns currently. Patient is alert and oriented and answers questions appropriately. Patient is accompanied by her mother during exam. The patient lives at home with Her Father, Mother and 5 siblings. Resides is a single-story home. Last wellness ...

NR511 Final study guide with complete solutions Define diagnostic reasoning - Answer- A list of possible diagnoses based on historical and clinical presentation listed in order of priority Identify subjective and objective data - Answer- Subjective data is what the patient tells you (SAYS) objective data is what you see: labs, etc. (OBSERVE) Identify the components of the HPI - Answer- OLDCARTS onset location duration characteristics aggravating factors relieving factors timing and...