*NURSING > QUESTIONS & ANSWERS > Scribe Final Exam Questions and Answers Rated A (All)

Scribe Final Exam Questions and Answers Rated A

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Scribe Final Exam Questions and Answers Rated A 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 symptoms have been present 3. Location 4. Quality 5. Severity 6. Modifying Factors 7. Pertinent positive and negatives Level 5 Chart ✔✔HPI: 4-7 ROS: 10+ PFSH: 2+ PEx: 8+ systems Supination ✔✔Turning the hand so that the palm faces upward. Volar ✔✔Pertaining to the palm of the hand or the sole of the foot. Inferior ✔✔Situated below or further away from the head. Midline ✔✔Line that divides the body into right and left halves. Abduction ✔✔Moving away from the midline. ACLS ✔✔Advanced cardiac life support. AMA ✔✔Against medical advice. DNR ✔✔do not resuscitate DOA ✔✔Dead on arrival OSH ✔✔Outside hospital PCP ✔✔Primary care physician PTA ✔✔Prior to arrival UTD ✔✔Up to date (as in immunizations) WNL ✔✔within normal limits yo ✔✔year old B/L ✔✔bilateral D/C ✔✔discharge H&P ✔✔history & physical nl ✔✔normal s/p ✔✔status post TTP ✔✔tenderness to palpation Proximal ✔✔closer to the body Lateral ✔✔farther from the midline Extension ✔✔straightening out Distal ✔✔farther from the body Adduction ✔✔Draws toward the midline Pronation ✔✔turning of the hand so the palm faces downward Posterior ✔✔situated behind or directed towards the rear Plantar ✔✔referring to the sole of the foot Inverted ✔✔turned inward Deep ✔✔Farther from the surface Flexion ✔✔bending or angulation Percussion ✔✔physician taps on a surface to determine t [Show More]

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