Multiple Choice Questions 1. Rosemary Lane told the healthcare professional that she has been suffering from a headache with pressure above her eyebrows and a low grade fever for the past four days. This is known as _______________. A. subjective information B. objective information C. an assessment D. a diagnosis 2. In a hospital setting, the care provider takes the patient 's history, details the reason the patient is being admitted and performs a physical exam. The report of this information is known as the: A. initial progress note B. discharge summary C. history and physical D. SOAP note 3. The SOAP documentation format is most commonly used in which healthcare setting? A. hospital inpatient B. physician 's …show more content…
Though they have helped reduce the pain somewhat, the patient would like to visit other options. This is known as the ____________ in a history of present illness (HPI). A. location B. timing C. severity D. modifying factors 9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit. A. care plan B. charges C. diagnosis D. assessment 10. Neil Rabinski was asked by the care provider if he has had any difficulty breathing, shortness of breath, or noticeable wheezing. This is part of the review of systems for the __________________ system. A. gastrointestinal B. head/eyes/ears/nose/mouth C. respiratory D. cardiovascular 11. The fact that a patient has experienced recent weight loss, fatigue, and loss of appetite would be included in which part of the review of systems (ROS)? A. general B. gastrointestinal C. neurologic D. constitutional 12. Which of the following professionals would not perform a physical examination (PE)? A. medical assistant B. physician 's assistant C. nurse midwife D. nurse practitioner 13. The healthcare professional who types reports for care providers is known as a/an ______________. A. dictator B. transcriptionist C. transcriber D. scribe 14. Which of the following is an advantage of dictation and transcription? A. most physicians prefer it to
1. As the clinic nurse, what routine information would you want to obtain from S.R.?
3. List and define each of the patient’s additional symptoms in your own words. These terms appear
B. Minor Point 2: Doctors are forced and have an obligation to relieve patients which means many doctors can be wrong about the information they collected.
Bedside reporting has the primary function of sharing patient information between nurses, as they change shifts. The nurse ending their shift would report all the changes that have occurred in the state of the patient and all measures which have been taken for the respective patient. This information would be transmitted to the nurse commencing her shift, who would then write and further transmit all patient information occurring during their shift, to the nurse coming to replace them.
Staff will receive written material outlining the role and importance of the history and physical exam in patient care. Signatures acknowledging receipt and understanding of materials will be collected by unit supervisors and submitted to HR to be included in the employees' files.
The physician performs a problem focused history and physical examination with straightforward decision making 99201
P5 – Explain the role of workforce development in the health sector In this assignment I will be explaining the role of workforce development in the health sector as a nurse and midwife and what their requirements are to ensure that what they do is done at the best of their ability. Workforce development covers educating, supporting, training and encourages and helps workforces to develop their skills. As a nurse/midwife, a requirement such as Continuing Professional Development known as (CPD) is vital and gives them great opportunities.
PO is referred to continue chemical dependence treatment at the community agency. PO will need to have a new assessment to determine appropriate level of care. PO is recommended to attend minimally of two self-help meetings per week, abstain from all mood-altering substance, and utilize positive support structure to aim and maintain substance free lifestyle.
Two patient verifier completed. Per PA Wu , the patient was informed that she has added an additional bp med to his current regimen. Asked the patient that he has any swelling in legs. The pt says no. Informed the patient that only a 30 day supply was ordered on his Lisinipril. Please record bp readings for the next seven days at the same time then email reading via Micare. If bp in not controlled then a f/u with his provider is needed. The patient agrees and verbalized
After Graduation in 2011 I was unable to find a job for several months dues to both the economy, and living in a rural area without reliable transportation. In 2013 Converge diagnostic was sold to quest, and relocated outside a reasonable commute distance. I could live off my emergency funds, until I was offered a position as a pathology tech at Lahey clinic and medical center.
Criteria: setting evaluation, contact was it direct or indirect, is patient a child or infant, service provided, is the patient established/new. Service level consist of three components, which is the history, exam, and decision made at the time of visit. Patient that has seen the doctor for three year is established. One that has not seen the doctor is new. There are four levels of making a decision. HPI factors relate to the issue the patients is dealing with. ROS factors relates to the sign of illness. PFSH factors deals with the history of the patient and history of the
Clinical documentation is vital to the success and care every clinical facility provides for their patients. It is a time-stamped process that includes all medical data performed by the hospital. It gives detailed analysis of procedures that were done, reasons why and past medical history. This gives the patient and hospital a detailed summary which helps improves the effectiveness
The most serious health problem that the client has is impaired gas exchange. According to Sue Galanes (2007), impaired gas exchange is result from the balance between ventilation and perfusion is offset by a certain condition which affects the efficiency of the gas exchange. On account of client has congestive heart failure that can contribute to dyspnea, which means the efficiency of gas exchange is decreased. One of the significant defining characteristics of impaired gas exchange is dyspnea (Sabtu, 03 Agustus 2013). In addition, it was hard for the patient to talk in long sentence due to difficulty in breathing. Hence, impaired gas exchange is one of the health problems that the client suffered from. In regards of O2 is the basic element that all of cells and organs need, it can be considered as a fuel of human body. Therefore, impaired gas exchange is the most severe health problem the patient has currently.
This reporter is a MSW intern at Banner Baywood Medical Center (BBMC), located in Mesa, Arizona. BBMC is a fully equipped hospital that serves the east valley with over 35 services some of which are inpatient and some being outpatient. To be more precise, this reporters title is discharge planner within case management on the Orthopedic unit.
The data are collected from observation of over 100 patients’ visits, 50 of which were observed and audio taped. The research questions that are asked by Davidson are: