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Pathophysiology sample values; BMP/ELECTROLYTES: Na + = 140 Cl − = 100 BUN = 20 / Glu = 150 \ K + = 4 CO 2 = 22 PCr = 1.0 ARTERIAL BLOOD GAS: HCO 3 − = 24 p a CO 2 = 40 p a O 2 = 95 pH = 7.40 ALVEOLAR GAS: p A CO 2 = 36 p A O 2 = 105 A-a g = 10 OTHER: Ca = 9.5 Mg 2+ = 2.0 PO 4 = 1 CK = 55 BE = −0.36 AG = 16 SERUM OSMOLARITY/RENAL: PMO ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
The Prescribing Information follows one of two formats: "physician labeling rule" format or "old" (non-PLR) format. For "old" format labeling a "product title" may be listed first and may include the proprietary name (if any), the nonproprietary name, dosage form(s), and other information about the product. The other sections are as follows:
The tests are classified by speciality field, conveying in which ward of a hospital or by which specialist doctor these tests are usually performed. The ICD-10-CM is generally the most widely used standard by insurance companies and hospitals who have to communicate with one another, for giving a overview of medical tests and procedures.
The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and health practices that are used to reach the current level of health or wellness. [1] [2] Health Perception and Management; Nutritional metabolic
Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). [1] Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response ...
A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...