Summary Study Guide for Final Exam: NURS 6800 Fall 2023/2024.
Study Guide for Final Exam: NURS 6800 General topics include, but are not limited to: Well child examination: Well visits including months 1, 2, 4, 6, 9, and 12, 15, 18, 24, SOAP notes: Meanings of SOAP: S: what the parent reports O: your assessment A: your diagnosis P: the plan This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan. Chief Complaint (CC) The CC or presenting problem is reported by the patient. This can be a symptom, condition, previous diagnosis or another short statement that describes why the patient is presenting today. The CC is similar to the title of a paper, allowing the reader to get a sense of what the rest of the document will entail. Examples: chest pain, decreased appetite, shortness of breath. However, a patient may have multiple CC’s, and their first complaint may not be the most significant one. Thus, physicians should encourage patients to state all of their problems, while paying attention to detail to discover the most compelling problem. Identifying the main problem must occur to perform effective and efficient diagnosis. History of Present Illness (HPI) The HPI begins with a simple one line opening statement including the patient's age, sex and reason for the visit. Example: 47-year old female presenting with abdominal pain. This is the section where the patient can elaborate on their chief complaint. An acronym often used to organize the HPI is termed “OLDCARTS”: Onset: When did the CC begin? Location: Where is the CC located? Duration: How long has the CC been going on for? Characterization: How does the patient describe the CC? ..................
Schule, Studium & Fach
Dokument Information
- Hochgeladen auf
- 22. august 2023
- Anzahl der Seiten
- 16
- geschrieben in
- 2023/2024
- Typ
- ZUSAMMENFASSUNG
Themen
- nurs 6800n
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study guide for final exam nurs6800
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study guide for final exam nurs 6800
