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9-21 after break. See lecture 9-28.2 for etymology
Lecture 6
Lecture 6
guest04f1905
Documenting challenging patient conditions is a tiresome task for nurses. This article explains some such conditions and nurses can document each condition.
Nursing documentation for challenging patient conditions
Nursing documentation for challenging patient conditions
Medical Transcription Service Company
heart failure
heart failure
Sohail Khan
Cardiac Assessment - BMH/Tele
Cardiac Assessment - BMH/Tele
TeleClinEd
Cardiodrugs
Cardiodrugs
Tosca Torres
course material
Coding of Case013 Assignment.docx
Coding of Case013 Assignment.docx
studywriters
Communication and Documentation
Communication and Documentation
paramedicbob
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic! Search reputable local and national media for a man-made disaster to discuss. Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks. In your initial post, describe the incident and address the following: · Determine the incident type and explain your reasoning. · What resources were deployed for this incident? · What protocols were implemented successfully, and which were unsuccessful? · Discuss way to improve the response to this type of incident in the future. Support your answer with evidence. Please provide a working link to your story source. NUR 634 SOAP Note Guide and Template Patient SOAP Note Charting Procedures S = Subjective O = Objective A = Assessment P = Plan Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it. Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing. Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI. Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded. SOAP NOTE TEMPLATE **Please delete the instructions in each section prior to submitting the assignment Student Name: Date: Course: Subjective: Patient Demographics: (age, gender, gender identity, ethnicity, etc.) Chief Complaint: “quote patient” History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS) PMH: dates in reverse chronological order. PSH: surgery dates in reverse chronological order. Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies Untoward Medication Reactions: include type ...
For this weeks discussion, we will be looking at local or nationa
For this weeks discussion, we will be looking at local or nationa
ShainaBoling829
Recommandé
9-21 after break. See lecture 9-28.2 for etymology
Lecture 6
Lecture 6
guest04f1905
Documenting challenging patient conditions is a tiresome task for nurses. This article explains some such conditions and nurses can document each condition.
Nursing documentation for challenging patient conditions
Nursing documentation for challenging patient conditions
Medical Transcription Service Company
heart failure
heart failure
Sohail Khan
Cardiac Assessment - BMH/Tele
Cardiac Assessment - BMH/Tele
TeleClinEd
Cardiodrugs
Cardiodrugs
Tosca Torres
course material
Coding of Case013 Assignment.docx
Coding of Case013 Assignment.docx
studywriters
Communication and Documentation
Communication and Documentation
paramedicbob
For this week's discussion, we will be looking at local or national response protocols that were initiated during a critical incident, and you will choose your topic! Search reputable local and national media for a man-made disaster to discuss. Search for critical instances such as: hostage situations, mass shootings, multiple-vehicle or mass transit accidents with multiple critical injuries, and disease outbreaks. In your initial post, describe the incident and address the following: · Determine the incident type and explain your reasoning. · What resources were deployed for this incident? · What protocols were implemented successfully, and which were unsuccessful? · Discuss way to improve the response to this type of incident in the future. Support your answer with evidence. Please provide a working link to your story source. NUR 634 SOAP Note Guide and Template Patient SOAP Note Charting Procedures S = Subjective O = Objective A = Assessment P = Plan Subjective: Information the patient tells the treating team or patient advocate. Symptoms, not signs. These are typically not measurable, such as pain, nausea, and tingling, hence the term “subjective” as opposed to “objective”. Normally, the practitioner is not aware of this information until the patient provides it. Objective: Information gathered by the treating team or provider which is typically observable and measurable, hence “objective” as opposed to “subjective”. Normally, the patient is not aware of this information until the practitioner elicits it. This might include, for example, ranges of motion, body temperature, blood pressure, the presence of a skin rash or wound, comments about the patient’s posture or gait, and the results of examination procedures and testing. Assessment: The diagnosis. This must be documented prior to the rendering or delivery of any treatment. Symptom code can be documented as assessment when pending final diagnosis such as Chest pain vs. MI. Plan: Based on the assessment or diagnosis, the treatment or therapeutic plan must be outlined. This may include both short and long term plans. It is important to record not only passive therapy, such as an injection, a prescription, a spinal manipulation or a massage, but also active therapy such as home care advice, exercises or other recommendations. All treatment planned or delivered must be recorded. SOAP NOTE TEMPLATE **Please delete the instructions in each section prior to submitting the assignment Student Name: Date: Course: Subjective: Patient Demographics: (age, gender, gender identity, ethnicity, etc.) Chief Complaint: “quote patient” History of Present illness: (Be sure to tell the “story” of the cc using the 7 attributes or OLDCARTS) PMH: dates in reverse chronological order. PSH: surgery dates in reverse chronological order. Allergies: medications, OTCs, supplements, & environmental/seasonal/food allergies Untoward Medication Reactions: include type ...
For this weeks discussion, we will be looking at local or nationa
For this weeks discussion, we will be looking at local or nationa
ShainaBoling829
The Nuts And Bolts Of E&M Coding
The Nuts And Bolts Of E&M Coding
Angie Nolan
Coding BAsics and how to proceed
Coding Lecture 2013 Zesut for learning how to code
Coding Lecture 2013 Zesut for learning how to code
SDanishHasan1
History taking in Ophthalmology
History taking
History taking
Raju Kaiti
Making medical documentation simple and painless with template based documentation tools. Prompters help remind users about the 1997 E&M Documentation guidelines, to help insure compliance with the requirements for the highest levels of medical billing.
Medical Templates Making Medical Documentation Simple And Painless
Medical Templates Making Medical Documentation Simple And Painless
e-MedTools
CSM 2009: The nuts and bolts of outcomes
You Don’t Know What You Don’t Know! Part 1
You Don’t Know What You Don’t Know! Part 1
Selena Horner
course materials
Pneumonia Soap Note Acute Conditions Paper.pdf
Pneumonia Soap Note Acute Conditions Paper.pdf
sdfghj21
Progress notes and patient records are the medical translator's bread and butter, but this doesn't prevent even the most experienced medical translators from getting burnt. We'll take a closer look at the SOAP (Subjective, Objective, Assessment, Plan) format to understand how doctors think. We'll use the tool to understand why "BS" could mean "blood sugar," "breath sounds," or "bowel sounds." We'll also build a kit of multilingual resources for the review of systems, lab reports, etc. Finally, we'll address capturing succinct source-language style in a translation that is meaningful and not unduly conservative.
SOAP Notes: Getting Down and Dirty with Medical Translation
SOAP Notes: Getting Down and Dirty with Medical Translation
Erin Lyons
A Little Look at Big Data
CSM 2017 Stout
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Pneumonia Of Left Lung Essay.docx
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A practical guide to clinical medicine
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Dr. Kenneth Antonio, MD,PhD,MPrS-MPA,BSMT
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Imhotep Virtual Medical School
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Skills-based sign-out workshop that focuses on teaching interns and students how to create and update a written sign-out and how to perform a verbal handover. Used at orientations for interns or sub-interns.
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Key Performance Indicator Assignment: Capstone Written Case Conceptualization (20 points) (The client selected should be a high school student. I did my intern at a high school) The student will select a client from their internship site and complete an 8-page (minimum) case conceptualization report detailing the following ten competencies, 1. Assessment Skills: Includes a summary of the DSM-5 diagnosis, biopsychosocial assessment, mental status exam, substance use, risk assessment, and any other assessment instruments used. 2. Intervention & Conceptualization Skills: Includes a summary of how the assessment informs treatment, treatment plan, goals, and interventions used. Incorporates any relevant cultural, racial, ethical, and legal (if applicable) issues related to the case, and reflects the intern’s personal theory of counseling. 3. Writing Skills and Document Organization: Paper clearly and succinctly communicates clinical impressions. Paper is organized, with appropriate grammar, spelling, and APA Style. 4. Use of Supervision: Includes a summary of how supervision impacted clinical decision making and case conceptualization. 5. Knowledge & Application of Site-Specific Information: Includes a description of how the site’s clinical services and structure affect the assessment, treatment, and conceptualization of the selected case. Any relevant policies, regulatory processes, and program evaluation measures associated with service delivery are included. 6. Professional Counseling Competencies: Includes a description of how the case was conceptualized from the professional counseling framework compared to other mental health professions (e.g., counseling promotes clients' optimal human development, wellness, and mental health through prevention, education, and advocacy activities, including advocacy for those with mental health issues.) 7. Personal Attributes & Self-Understanding: Includes a summary of 1. intern’s reactions, awareness of own emotional response, and effective countertransference management related to the client case, and 2. awareness of intern’s impact on client (i.e., intern’s race, gender, religion) and client’s transference responses. 8. Interpersonal Competencies: Includes a summary of how the intern’s interactions with supervisor, interdisciplinary team, and site colleagues informed the case. Describe how the use of Generated: 10/22/2021 Page 7 of 23 empathy, compassion, and respect for client’s autonomy were evident in the client’s treatment. 9. Student’s Strengths: Identify and describe at least three of the intern’s personal strengths that enhanced the client’s treatment. 10. Student’s Areas for Development: Identify and describe at least three of the intern’s areas for development that would further enhance the client’s treatment. This paper must be written in APA Style Due date 11/13/21 Please see attached “final capstone correct” I have started the paper but I need help completing the rest. I have in ...
Key Performance Indicator Assignment Capstone Written Case Concep
Key Performance Indicator Assignment Capstone Written Case Concep
TatianaMajor22
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric. TO be successful in the clinical setting do the following: You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log). Do Not change the template. Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template. READ every line of this document please. You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric. All grades are final. No revisions. Do not ask for revisions of SOAP grades. Nurse Practitioner SOAP Notes Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. DO NOT INCLUDE IN NOTE Subjective data value @ 15 points SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5 Onset Location Duration Characteristics Aggravating Factors Relieving Factors Treatments/Therapies Each of these are valued at 0.5 points (maximum 4 points) Medications: list each one by name with dosage and frequency Allergies: include specific reactions to medications, foods, insects, environmental Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses Past Surgical History (PSH): Dates, indications and types of operations OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) Family History: Parents, Grandparents, siblings, children Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points General: any recent weight changes, weakness, fatigue,.
APA Title page, running head, page numbers, reference sheet. Use L.docx
APA Title page, running head, page numbers, reference sheet. Use L.docx
justine1simpson78276
5)Documentation
5)Documentation
phant0m0o0o
internal medicine mcq
03.Lange Q A Internal Medicine 5th ed.pdf
03.Lange Q A Internal Medicine 5th ed.pdf
ShriefElghazaly
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Key Performance Indicator Assignment: Capstone Written Case Conceptualization (20 points) (The client selected should be a high school student. I did my intern at a high school) The student will select a client from their internship site and complete an 8-page (minimum) case conceptualization report detailing the following ten competencies, 1. Assessment Skills: Includes a summary of the DSM-5 diagnosis, biopsychosocial assessment, mental status exam, substance use, risk assessment, and any other assessment instruments used. 2. Intervention & Conceptualization Skills: Includes a summary of how the assessment informs treatment, treatment plan, goals, and interventions used. Incorporates any relevant cultural, racial, ethical, and legal (if applicable) issues related to the case, and reflects the intern’s personal theory of counseling. 3. Writing Skills and Document Organization: Paper clearly and succinctly communicates clinical impressions. Paper is organized, with appropriate grammar, spelling, and APA Style. 4. Use of Supervision: Includes a summary of how supervision impacted clinical decision making and case conceptualization. 5. Knowledge & Application of Site-Specific Information: Includes a description of how the site’s clinical services and structure affect the assessment, treatment, and conceptualization of the selected case. Any relevant policies, regulatory processes, and program evaluation measures associated with service delivery are included. 6. Professional Counseling Competencies: Includes a description of how the case was conceptualized from the professional counseling framework compared to other mental health professions (e.g., counseling promotes clients' optimal human development, wellness, and mental health through prevention, education, and advocacy activities, including advocacy for those with mental health issues.) 7. Personal Attributes & Self-Understanding: Includes a summary of 1. intern’s reactions, awareness of own emotional response, and effective countertransference management related to the client case, and 2. awareness of intern’s impact on client (i.e., intern’s race, gender, religion) and client’s transference responses. 8. Interpersonal Competencies: Includes a summary of how the intern’s interactions with supervisor, interdisciplinary team, and site colleagues informed the case. Describe how the use of Generated: 10/22/2021 Page 7 of 23 empathy, compassion, and respect for client’s autonomy were evident in the client’s treatment. 9. Student’s Strengths: Identify and describe at least three of the intern’s personal strengths that enhanced the client’s treatment. 10. Student’s Areas for Development: Identify and describe at least three of the intern’s areas for development that would further enhance the client’s treatment. This paper must be written in APA Style Due date 11/13/21 Please see attached “final capstone correct” I have started the paper but I need help completing the rest. I have in ...
Key Performance Indicator Assignment Capstone Written Case Concep
Key Performance Indicator Assignment Capstone Written Case Concep
TatianaMajor22
APA Title page, running head, page numbers, reference sheet. Use Level 1 and 2 headings to make identifying the components of the paper easier. – 5 points after grade calculated from rubric. TO be successful in the clinical setting do the following: You need a APA cover sheet, running head and reference page for anything you turn in (Journal, SOAP note, Time Log). Do Not change the template. Do use the template located in the Doc Sharing. This is the explanation of the template…this is not the template. READ every line of this document please. You must site 2 journal articles in addition to Epocrates/Medscape and text book failure to do so is -10 points outside of the rubric. All grades are final. No revisions. Do not ask for revisions of SOAP grades. Nurse Practitioner SOAP Notes Purpose: To explain what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise. DO NOT INCLUDE IN NOTE Subjective data value @ 15 points SUBJECTIVE DATA: What the patient tells you but organized by you in logical fashion Chief Complaint (CC): One to three words explaining why patient came to clinic value 1 point History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 34-year-old AA male) Must include the 7 attributes of each principal symptom: value 7 points hint: OLD CART Write your paragraph in the order of old cart & chart as well if missing paragraph -3.5 if missing list -3.5 Onset Location Duration Characteristics Aggravating Factors Relieving Factors Treatments/Therapies Each of these are valued at 0.5 points (maximum 4 points) Medications: list each one by name with dosage and frequency Allergies: include specific reactions to medications, foods, insects, environmental Past Medical History (PMH): Illnesses, hospitalizations, risky sexual behaviors. Include childhood illnesses Past Surgical History (PSH): Dates, indications and types of operations OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function Personal/Social History: Tobacco use, Alcohol use, Drug use. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history etc Immunizations: Last Tdp, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) Family History: Parents, Grandparents, siblings, children Review of Systems: Go Head to toe. Cover each system that covers the Chief Complaint, History of Present Illness and History (this includes the systems that address any previous diagnoses). YOU DO NOT NEED TO DO THEM ALL UNLESS YOU ARE DOING a TOTAL H&P. Remember, this is what the patient tells you. Delete the system if not addressing. DO NOT put wnl or no complaints be specific. Value 3 points General: any recent weight changes, weakness, fatigue,.
APA Title page, running head, page numbers, reference sheet. Use L.docx
APA Title page, running head, page numbers, reference sheet. Use L.docx
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Lecture 3
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V550 The History
Questions Richard E. Meetz, OD, MS 2009
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