Soap note format Study guides, Class notes & Summaries
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NSG6020 Final Exam Questions and Answers Already Passed
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NSG6020 FiNSG6020 Final Exam Questions and Answers Already Passed The brain and spinal cord are included in which of the following? Central nervous sytsem 
The cranial nerves 31 pairs of spinal nerves, and branches make up which of the following? Peripheral nervous system 
A rotational sensation of spinning is considered to be which of the following? Vertigo 
A sensation of numbness and or tingling of the extremities is referred to as which of the following? Paresthesia 
Lightly touching the cor...
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NHA Medical Assistant (CCMA) Exam solution Test bank 2022.
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NHA Medical Assistant (CCMA) Exam solution Test bank. 
 
Where do cardiac electrical impulses originate in the heart? - Sinoatrial node 
 
According to the regulation of controlled substances, which of the following is true of a Schedule 1 drug? - have no accepted medical use 
 
A medical assistant is collecting a health history from an older adult patient who exhibits moderate hearing loss. What following action should the assistant take? - remain within the patient's view to allow lip-reading...
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OSC test Questions and Answers Guaranteed Success
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OSC test Questions and Answers Guaranteed Success 
 
what is the primary function of a medical scribe? 
create the medical note 
what is the preferred format for the creation of the medical note? 
subjective, pbjective, assessment, plan (soap) 
"present time" pt details are summarized by using what format 
OPQRST 
all current procedural terminology (CPT) codes must be justified by what appropiate coding mechanisms 
international classification of disease (ICD) 
what patient history is outlined...
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NRS 2024: Exam with Guaranteed Accurate Answers
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Which is not a purpose of the client care record? 
 
a. To serve as a legal document. 
b. To facilitate reimbursement 
c. To serve as a contract with the client. 
d. To assist with care planning. - correct answer c 
 
Which is the primary purpose of client records? 
 
a. Communication 
b. Reimbursement 
c. Legal protection 
d. Performance improvement - correct answer a 
 
Which note includes all elements of a SOAP note? 
 
a. Client reports nausea, including one episode of nausea yesterday. Also...
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NR 602 WK 5SOAP NOTE FORMAT - JO
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NR 602 WK 5SOAP NOTE FORMAT - JO 
 
 
 
NR 602 WK 5 
 
SOAP Note Format - Jo 
 
Patient Information: J.F., 6y/o Caucasian girl S. 
CC (chief complaint) – “Vomiting, diarrhea and fever” 
 
HPI: 6 old girl p/w vomiting x2 days/diarrhea x1 day/fever 100-101degrees/severe lower abd pain x1 day. Last meal was at a pizza buffet 36hrs ago, otherwise no solid foods since then, consumed sprite, apple juice and popsicles instead. Administered Pepto-Bismol (OTC) & Tylenol x2-3/day for fever. There ar...
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321 Coding Final- Chapters 1-9 Fall 2023 Questions and Answers
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321 Coding Final- Chapters 1-9 Fall 2023 Questions and Answers 
 
An at-home coding specialist assigns ICD-10-CM codes for a patient with hypertension. Which type of HIPAA code set is being used? 
Diseases, injuries, impairments, and other health-related problems 
A facility enters into a contract with a billing service to convert health information and claims from a nonstandard to a standard format. The billing service is considered a(n): 
health care clearinghouse 
A claims examiner reviews a ...
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RHIA Exam Prep | 50 Questions with 100% Correct Answers | Verified | Latest Update 2024
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The Medical Record Committee is deciding how interim reports should be handled. What is the best 
practice? - Maintain all interim reports for the greatest measure of security 
This report should be written or dictated immediately after the procedure is done and filed in the 
patient's health record as soon as possible. - Operative Report 
Highland Hospital requires all dates be recorded as MM/DD/YYYY. This required data definition and 
format should be part of the _____ _____. - Data Dictionar...
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OSC Test Questions & Answers
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OSC Test Questions & Answers 
 
what is the primary function of a medical scribe? - create the medical note 
 
what is the preferred format for the creation of the medical note? - subjective, pbjective, 
assessment, plan (soap) 
 
"present time" pt details are summarized by using what format - OPQRST 
 
all current procedural terminology (CPT) codes must be justified by what appropiate coding 
mechanisms - international classification of disease (ICD) 
 
what patient history is outlined in the...
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ATI RN Concept-Based Assessment Level 1 Practice B (Latest 2023/ 2024) Questions and Verified Answers | 100% Correct| Grade A
- Exam (elaborations) • 34 pages • 2023
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ATI RN Concept-Based Assessment Level 1 Practice B (Latest 2023/ 2024) Questions and Verified Answers | 100% Correct| Grade A 
 
Q: A nurse is teaching a client to self-administer 8 units of NPH insulin and 2 units of regular insulin in the same syringe. Which of the following client statements indicates an understanding of the teaching? 
 
A. "I'll draw up regular insulin into the syringe before the NPH insulin." 
B. "I'll inject air into the regular insulin vial before the NPH vial." 
C....
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NSG 526 Exam 1 Question and answers 100% correct
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NSG 526 Exam 1 Question and answers 100% correct NSG 526: Exam 1 
 
 
DSM-5 TR: How is it utilized? - correct answer Utilized in diagnostic assessment process only, 
 
DSM-5 TR: What does it not suggest? - correct answer Treatment strategy. 
 
Accurate Documentation: Why is it significant? - correct answer Significant for legal protection, regulatory standards compliance, reimbursement, liability reduction, consistency in therapeutic intervention, and assistance with utilization review. 
 
Jo...
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