Health Information Documentation
Unit III Essay
Data Entry at the Point of Care
After reading the required chapter on Data Entry at the Point of Care, compose an essay that addresses the following.
Begin your essay with an introduction explaining the purpose of the essay.
Differentiate between lists and forms.
Explain the term review of systems (ROS). Describe the functions of the ROS button located on the Toolbar.
HTH 2305, Health Information Documentation Management 2
Discuss the components of subjective objective assessment plan (SOAP) charting for the following scenario, and include the list and forms that may be used.
Scenario: A 21-year-old female has come to the physician complaining of chest pains with shortness of breath. She says she has been wheezing and coughing for one week. Her vital signs are P-150, B/P – 150/100, R – 60, T – 99.6. Following a physical examination, the physician decides she has been experiencing tachycardia and has seasonal asthma. The physician gives the medical assistant an order to administer a breathing treatment using the nebulizer and 2.0 mg of albuterol sulfate. Then the medical assistant is to take the female’s vital signs again.
Close your essay with a conclusion section that sums up your thoughts.
Your essay must be at least two pages in length, and you must use at least your textbook as a source. Other sources may be used as needed. Any information from a source must be cited and referenced in APA style, and your paper should be formatted according to APA guidelines.
Last Updated on February 11, 2019 by Essay Pro