Health Assessment HESI questions and answers

SOAP modified format - ANSWER-Subjective Objective Assessment Plan What color ink should be used when documenting on paper - ANSWER-Permanent black ink What is the correct order for vital signs - ANSWER-T, P, RR, BP, extremity, pt position, SPO2 What should be at the top of every page of documentation - ANSWER-Patient initials and date and time of entry What should be at the end of every documentation entry - ANSWER-Interviewers signature How do you correct a mistake in documentation - ANSWER-1) Draw a single line through the incorrect documentation 2) Write error above the entry 3) Initial and date the crossed out entry Documentation tips - ANSWER-1) Avoid complete sentences 2) Do not use A, an, the 3) Do not put opinion in notes 4) Avoid us