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The nurse is entering a note in the patient's medical record using the SOAP format.Which statement belongs in the Assessment section?
A) The patient stated "I started feeling short of breath after smelling strong perfume."
B) The patient is using accessory muscles and has wheezes in all lung fields.
C) Ineffective airway clearance related to exposure to environmental allergen.
D) Monitor pulse oximetry and administer nebulized bronchodilators.
SOAP Format
An organizational tool used in medical documentation standing for Subjective, Objective, Assessment, Plan to streamline patient information.
Assessment Section
Part of a document or examination that is dedicated to evaluating the condition, situation, or performance of an individual or system.
Accessory Muscles
Secondary muscles engaged during respiratory distress to aid in breathing, indicating increased effort or difficulty.
- Identify healthcare norms and criteria for precise, prompt, and patient-focused documentation.
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Learning Objectives
- Identify healthcare norms and criteria for precise, prompt, and patient-focused documentation.
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