Documenting patient history and physical examination

Assignment Help Science
Reference no: EM133723823

Question

The most commonly used approach for documenting the patient history and physical examination is the SOAP note. Determine a statement that reflects appropriate documentation using the SOAP note. Assessments are the information directly observed. Objective data can be obtained through observation. Therapeutic treatments are objective findings. Subjective data include a patient's plan of care.

Reference no: EM133723823

Questions Cloud

Completing history of present illness : A nurse practitioner is completing a history of present illness (HPI) on a new patient. Develop a statement that reflects information
Painful urination along with urinary frequency and urgency : A 64-year-old man with a history of prostatic hypertrophy presents with painful urination along with urinary frequency and urgency.
Patient complains of general weakness : A 58-year-old patient complains of general weakness, weight loss up to 10 kg within the last 1,5 months, progressive pain in the small of the back,
Addressing the needs of the older client with schizophrenia : Addressing the needs of the older client with schizophrenia. What is the first psychiatric priority in caring for this client?
Documenting patient history and physical examination : The most commonly used approach for documenting the patient history and physical examination is the SOAP note.
About your hypertension : Communication is important to obtaining an accurate health history. Can you please tell me more about your hypertension?
Obtaining health history information : In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information.
What is the clinical evidence for aortic dissection : What are the negative consequences of left ventricular hypertrophy? What is the clinical evidence for aortic dissection?
Patient-centered digital health records in chronic condition : The use of patient-centered digital health records in chronic conditions is potentially associated with beneficial effects on several patient-reported outcomes

Reviews

Write a Review

Science Questions & Answers

  Do you think caused the patient to have increased agitation

Which medication do you think caused the patient to have increased agitation and combative behavior - lorazepam, haloperidol, or diphenhydramine?

  Referencing podcast on asteroid deflection

Referencing podcast on Asteroid Deflection. A positive use for nuclear weapons is demonstrated. In fact, this idea was the basis of two movies in recent year

  Hit domains electronic health records-biometric devices

Describe how the HIT domains electronic health records, biometric devices, hospital management information systems, etc.

  Patient assessment while guiding development of plan

Clinical reasoning is pivotal to the patient assessment while guiding the development of a plan.

  Recently changed his eyeglass prescription

A patient has a history of hypertension and has recently changed his eyeglass prescription.

  Childhood or adolescent personality disorders

What is one developmental theory that relates to childhood or adolescent personality disorders?

  Handling incidents well helps keep your organization

Handling incidents well helps keep your organization from losing to attackers. A solid incident response plan is one that continually improves while directing

  Summary of security rules for destruction of health records

Using your own words: Provide a summary of the HIPAA Privacy and Security rules for the destruction of health records.

  Android-apple and gynoid-pear shaped obesity

Discuss the difference between android/apple and gynoid/pear shaped obesity. Find information to explain which is more of a risk to health and why.

  What are three unearned assets gained with this privilege

What are three unearned assets gained with this privilege? Describe a situation in which a person might believe they stereotyped someone negatively.

  Discuss how the peer review protection process

Discuss how the peer review protection process should be used in healthcare organizations to improve quality of care and patient safety.

  Management of health care organizations today

What is an important challenge facing the management of health care organizations today, and how would you go about addressing it? Explain your response.

Free Assignment Quote

Assured A++ Grade

Get guaranteed satisfaction & time on delivery in every assignment order you paid with us! We ensure premium quality solution document along with free turntin report!

All rights reserved! Copyrights ©2019-2020 ExpertsMind IT Educational Pvt Ltd