SOAP notes and medical charting Exam Quest And Verified Actual Answers 100% Guaranteed Success2024.

What does the S in SOAP stand for - correct answer Subjective: Describes the patients condition in a narrative form. How they describe what they're feeling What does the O in SOAP stand for - correct answer Objective: Documents and traceable facts about the patients status What does A in SOAP stand for - correct answer Assessment: the physicians medical diagnosis on the given date the SOAP note was written What does the P in SOAP stand for - correct answer Plan: describes what the health care provider will do to treat the patient What does "good writing" include - correct answer Logical organization Attention to detail Complete accuracy Why do we use SOAP notes - correct answer SOAP notes help pass along information for when patient care switches from one person to another. It also provides guidance for future encounters What should NEVER be in a SOAP note - correct answer Patient identifiable information: name, bday, SSN, phone #, hospital id #, address Must be neat and legible - correct answer True Must use correct spelling and grammar - correct answer True Quote patients words accurately - correct answer true Don't sign name and title - correct answer false Use objective observations - correct answer true Should you scribble out errors - correct answer No, cross it out with a single line, write error next to it, along with your initials Should you make up results - correct answer No Should you leave spaces blank - correct answer No Can you chart for someone else - correct answer No Patient Charts are... - correct answer property of the health facility Do not erase or obliterate on a chart - correct answer true Need written patient consent to... - correct answer release information All entries should be written in - correct answer blue or black ink (allergies in red) The identification sheet is also known as the - correct answer Face sheet Charts may include - correct answer H+P Physicians orders Nurses note Graphic chart Medication records Progress notes Reports and forms Labs Consults