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SOAP Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) 
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) 
Assessment-Diagnosis (determined by combining subjective/objective info) 
Plan-Disposition (Admission, Discharge, Transfer instructions) 
7 Parts of the HPI 1. Context 
2. Time/Duration; time = course of symptoms (improving, worsening, constant, intermittent, 
etc.); duration = total time symp... i x Exam (elaborations) • 27 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • Scribe 2022 Scribe America Final exam guide (AA) Latest 2022 (0) $8.49 0x sold Scribe America Final exam guide (AA) 
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1. CAD: Coronary Artery Disease 
2. HTN: Hypertension 
3. DM Diabetes Mellitus 
4. MI: Myocardial infarction 
5. CHF: Congestive heart failure 
6. AFIB: Atrial fibrillation 
7. PE: Physical exam or pulmonary embolism 
8. DVT: Deep Vein thrombosis 
9. DKA: Diabetic Ketoacidosis 
10. PTX: Pneumothorax 
11. COPD: Chronic Obstructive Pulmonary Disease 
12. PNA: Pneumonia 
13. GERD: Gastroesophageal Reflux Disease i x Exam (elaborations) • 11 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • Scribe America Scribe America Final Exam ED Questions and Answers Already Passed (0) $9.59 0x sold Scribe America Final Exam ED 
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What are the 3 types of dispositions? Discharge, Admit, Transfer 
What does HPI stand for? history of present illness 
What does ROS stand for? review of systems 
The HPI and ROS are considered what type of information? subjective 
The physical exam is what type of information? objective 
If a physician told you a patient's abdomen was non tender, where would you document this? 
PE 
What section focuses directly on the chief c... i x Exam (elaborations) • 24 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • Scribe America 2022 Medical Scribe- Final exam review questions and answers 100% pass (0) $8.89 0x sold Medical Scribe- Final exam review 
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What are the 5 vital signs? 1. Heart rate 
2. Blood pressure 
3. Respiratory rate 
4. Temperature 
5. Oxygen saturation 
The HPI and the ROS are what type of information? 
The physical exam is what kind of information? 
While evaluating a patient complaining of chest pain, your physician tells you that the heart 
sounds are normal. Would you document this in the HPI, ROS, or PE? Physical exam 
Would you be contradicting yours... i x Exam (elaborations) • 14 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • Medical Scribe- Scribe America Final Exam Review Questions and Answers 100% Pass (0) $9.49 0x sold Scribe America Final Exam Review 
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AAA Abdominal Aortic Aneurysm 
A Fib Atrial Fibrillation 
Abd Abdomen, Abdominal 
Abx Antibiotics 
AMA Against Medical Advice 
AMS Altered Mental Status 
ASA Acetylsalicylic Acid (Aspirin) 
BID Twice Daily 
Bilat LE Bilateral Lower Extremities 
BM Bowel Movement 
BP Blood Pressure 
CA Cancer, Carcinoma 
CABG Coronary Artery Bypass Graft, "open heart surgery i x Exam (elaborations) • 21 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • Scribe America 2022 Introduction to Communication – WGU C464/ Competency 2: Communication Strategies- 39% of assessment (0) $6.09 0x sold Introduction to Communication – WGU 
C464/ Competency 2: Communication 
Strategies- 39% of assessment 
Johari window definition A model that describes the relationship between self-disclosure and 
self-awareness. 
The Johari Window (4 parts)- OHBU 1. Open 
2. Hidden 
3. Blind 
4. Unknown 
Social Penetration Theory describes how disclosure typically progress in two ways- Breadth 
and Depth 
Social Penetration Theory- two key components- B/D Breadth- the range of topics on which 
disclosure... i x Exam (elaborations) • 4 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • WGU C464/ Introduction to Communication – Immune & HIV practice for Exam Questions with 100% correct Answers (0) $8.99 0x sold Immune & HIV practice for Exam 
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A nurse is caring for a group of clients. For which of the following tasks should the nurse wear gloves? 
(Select all that apply.) 
a. Emptying urine from an indwelling urinary catheter collection bag 
b. Providing oral care 
c. Changing an ostomy pouch 
d. Delivering a food tray to a client who has AIDS 
e. Placing oral medication tablets into a client's hand - Ans-a. Emptying urine from an indwelling urinary 
catheter coll... i x Exam (elaborations) • 18 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • Immune & HIV Practice IDC1 - Pre-Assessment Questions and Answers Already Passed (0) $8.49 0x sold IDC1 - Pre-Assessment Questions and 
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Why conduct a needs analysis? Establish a standard or goal 
Determine the existing level of performance 
Identity a gap between the desired status and actual status 
Local school students' performance on state content standards State Education Offices 
Candidates position on an issue League of Women Voters 
Creation of an operation manual for aircraft instrumentation Aircraft instrumentation designers 
Regional unemployment rates Bur... i x Exam (elaborations) • 9 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • IDC1 - Pre-Assessment IDC1 WGU Questions and Answers Already Passed (0) $6.19 0x sold IDC1 WGU Questions and Answers 
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Purpose of needs analysis? 1. identify learning gaps-determine problem 
2. identify instructional goal 
3. identify current/desired condition 
Interview VS. focus group interview= 1 respondent 
focus group=more than 1 respondent 
components of goal statements AKA instructional goals 
1. learner(s) 
2. action (what will students do?) 
3. context to which skills are applied 
4. tools they will need to complete skill 
What is a task analysis? AKA: go... i x Exam (elaborations) • 5 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • IDC1 WGU DC1 Questions and Answers Latest Updated 2022 (0) $6.49 0x sold IDC1 Questions and Answers Latest 
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Facilitating a student's direction of thought (e.g., hints) to help the learner stay on track toward 
knowledge acquisition is which of Gagne's Nine Events of Instruction Eliciting performance 
What is the first step in Wiggins Backward Design Identifying desired results 
What are the 3 steps of Backwards Design 1. Identify the result 
2. Determine acceptable evidence 
3. Plan the learning experiences 
What is the second step in Wiggins' Back... i x Exam (elaborations) • 4 pages • by Shiku • uploaded 2022 Quick View i x Western Governors University • IDC1 WGU 1 ... 23 24 25 ...