What is a soap note - Study guides, Class notes & Summaries

OTD 355: Exam 2 Questions & Answers 2024/2025 subjective part of SOAP note - player interview - ANSWERSclient's objective comments that should be relevant to the treatment session objective part of SOAP note - commentator play-by-play - ANSWERSrecords of the session/ client's performance, data (from assessments), acts, observations - inclusion of formal/informal/functional assessments and observations during functional performance statement about the setting and purpose/fo...

CDA EXAM LATEST 2023 REAL EXAM 150 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) GRADED A Ms. Hart walks toddlers through the neighborhood several times a week. Which strategy makes for the best learning experience? A: Telling the children about how the neighborhoods has changed over time. B: Permitting the children to pick any flowers or leaves they encounter. C: Taking one path often enough to observe and talk about what is there. D: Taking a diff...

A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. ...

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...

Test bank-CURRENT Medical Diagnosis and Treatment- Latest 2022. Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse: 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds. 3) washes hands only after leaving each room. 4) uses cold water for medical asepsis. 2. What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from ...

NR606 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 o...

Which of the following aptitudes related to health improvement involves creating a sense of autonomy, competence, and relatedness to life? a. The ability to enjoy b. The ability to choose c. The ability to keep developing d. The ability to see meaning C From a coaching perspective, what is often a major limitation for client success? a. A client's inner critical voice b. A client's listening skills c. A client's lack of knowledge d. A client's schedule A Which of the ...

Subjective data --> what the patient says Objective data --> what you observe, such as VS, lab results, and physical assessment findings Assessment --> interpret the subjective and objective data and state the problem or note client progress on the problem (may be in the form of a nursing diagnosis) -Plan --> plan of care to address the problem Correct Answer-What is SOAP charting? Format: (Prohibited abbreviation ) = (Correct term) -U = unit -IU = International Unit -Q.D...

ATI PN CAPSTONE 1,2&3 QUESTIONS BANK-QUESTIONS AND ANSWERS FOR 2023 UPDATE1ATI PN CAPSTONE 1,2&3 QUESTIONS BANK-QUESTIONS AND ANSWERS 2023 UPDATE CAPSTONE 1 1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse anticipate that the client has problems with: a. Body temperature control. b. Balance and equilibrium c. Visual acuity d. Thinking and reasoning 2. A female client admitted to an acute care facility after a car accident de...

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...