NR576 WEEK 1 QUESTIONS AND ANSWERS
ELABORATIONS
Diagnostic reasoning
Answers:the process of analyzing health data and drawing conclusions to identify
diagnoses
differential diagnosis
Answers:a list of potential diagnoses compiled early in the assessment of the
patient
Working list of potential problems
subjective data
Answers:things a person tells you about that you cannot observe through your
senses; symptoms
Data obtained from the hx
What the patient reports
What the patient complains of verbally
What the patient tells u in response to your questions
chief complaint
Answers:the main reason for the patient's visit
Example ... cough
If multiple cc... choose the highest priority or most important to the patient
OLD CARTS/ (HPI)
Answers:Onset
, Location
Duration
Characteristics
Aggravating
Relieving
Treatments tried
Severity
SOAP notes
Answers:subjective, objective, assessment, plan
"S" of the soap note
Answers:Includes ...
PMH
SH
PSH
Medications
ROS
all subjective information
objective data
Answers:information that is seen, heard, felt, or smelled by an observer; signs
"O" of the soap note
Answers:Includes lab tests and test results
ELABORATIONS
Diagnostic reasoning
Answers:the process of analyzing health data and drawing conclusions to identify
diagnoses
differential diagnosis
Answers:a list of potential diagnoses compiled early in the assessment of the
patient
Working list of potential problems
subjective data
Answers:things a person tells you about that you cannot observe through your
senses; symptoms
Data obtained from the hx
What the patient reports
What the patient complains of verbally
What the patient tells u in response to your questions
chief complaint
Answers:the main reason for the patient's visit
Example ... cough
If multiple cc... choose the highest priority or most important to the patient
OLD CARTS/ (HPI)
Answers:Onset
, Location
Duration
Characteristics
Aggravating
Relieving
Treatments tried
Severity
SOAP notes
Answers:subjective, objective, assessment, plan
"S" of the soap note
Answers:Includes ...
PMH
SH
PSH
Medications
ROS
all subjective information
objective data
Answers:information that is seen, heard, felt, or smelled by an observer; signs
"O" of the soap note
Answers:Includes lab tests and test results