A nurse is using SOAP format to document a client’s progress note.
What does SOAP stand for?
Subjective, Objective, Assessment, Plan.
Situation, Observation, Action, Problem.
Summary, Outcome, Analysis, Process.
Source, Opinion, Accuracy, Purpose.
The Correct Answer is A
Subjective, Objective, Assessment, Plan. This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.
Choice B is wrong because Situation, Observation, Action, Problem is not a documentation method, but a communication tool used in handovers and briefings.
Choice C is wrong because Summary, Outcome, Analysis, Process is not a documentation method, but a framework for writing reflective essays.
Choice D is wrong because Source, Opinion, Accuracy, Purpose is not a documentation method, but a criteria for evaluating information sources.
SOAP format helps to organize the information collected from the patient in a clear and consistent manner.
It consists of four components:.
• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.
• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.
• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.
• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.
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Related Questions
Correct Answer is A
Explanation
Home health certification and plan of treatment.This is the record that the nurse uses to certify that the client meets Medicare eligibility criteria and to outline the services to be provided.A home health certification and plan of treatment is a document that contains the physician’s or allowed practitioner’s orders for home health services, the patient’s diagnosis, the patient’s functional limitations, the type and amount of services needed, and the expected duration of care.
Choice B is wrong becauseOutcome and Assessment Information Set (OASIS)is a standardized assessment tool that HHAs use to collect data on adult patients receiving skilled services.
OASIS is not used to certify eligibility or plan treatment.
Choice C is wrong becauseHome care flow sheetis a form that HHAs use to document the daily care provided by nurses and home health aides.
A home care flow sheet does not certify eligibility or plan treatment.
Choice D is wrong becauseHome care progress noteis a form that HHAs use to document the patient’s progress toward the goals of care, any changes in the plan of care, and any communication with other health care providers.
A home care progress note does not certify eligibility or plan treatment.
Correct Answer is C
Explanation
Assess the client’s understanding and readiness for discharge.
This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.
The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.
Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.
The nurse should not threaten or coerce the client to stay in the hospital against his will.
Choice B is wrong because it is not the priority at this time.
The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.
Choice D is wrong because it is not the first action that the nurse should take.
The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.
A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.
Some of the benefits of cardiac catheterization are:.
• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.
• It can help determine the best treatment plan for the client based on his or her specific condition and needs.
• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.
• It can reduce the need for more invasive surgery or repeated hospitalizations.
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