Dr. Balby writes the following note: Onset of contractions started at 4:00 a.m. Patient refused medications. Normal presentation. Outcome of delivery: single male infant. This information would be documented as part of the:
A) antepartum record
B) labor and delivery record
C) prenatal record
D) postpartum record
Question 2
Dr. Jones reviews the following information located in the patient record. In which report is the information documented?
Date
1/2/YYYY
1/3/YYYY
1/4/YYYY
1/5/YYYY
1/6/YYYY
1/7/YYYY
Blood Pressure
130/75
128/78
120/75
130/80
135/80
130/78
Temperature
99.3
99.5
99.8
99.5
99.8
99.9
Weight
139
139
137
137
136
138
A) history of present illness
B) physical examination
C) nursing care plan
D) vital signs record
Patient learns to not be afraid
Algorithm for assessing a patient at risk for self-directed violence.
Kaposi's sarcoma on the skin of an AIDS patient.
Summary of SOAP Note Content