course 5 A/P

Question 1

Assessment is what, what MUST it include at a minimum

Answer 1

Diagnosis + Summary of visit. age/sex, Dx or DDx.

Question 2

What is the assessment used for

Answer 2

note to self for when the doctor looks at the patient file again and can recall what happened in the last visit

Question 3

Relevant OBJECTIVE information that can be included in assessment

Answer 3

relevant exam findings, NEW and RELEVANT results

Question 4

Most important thing to thikn about when writing the assessment

Answer 4

it’s an overall summary of the visit

Question 5

Formula for summarizing test results

Answer 5

Name of test, Result of test, Why it was ordered (r/o or confirming). (Ex. XR of L wrist was negative, r/o radial fracture)

Question 6

What is the Plan

Answer 6

A list outlining how the doctor will treat or monitor the patient.

Question 7

Where does the plan go in the chart

Answer 7

at the very bottom

Question 8

How do you hear the plan information

Answer 8

doctor will speak verbatim

Question 9

What does plan include

Answer 9

Treatments for EACH diagnosis, Prescriptions, ORDERED tests, Follow up with OTHER healthcare providers in ____ time, Follow up here in ____ time

Question 10

How is the plan written

Answer 10

Bulleted or numbered list