Asked by Hinal Bhatt on Jul 02, 2024

A nurse records the following: "Patient is wheezing and experiencing some dyspnea on exertion." This represents which of the following?

A) The "S" in SOAP documentation.
B) Focus documentation.
C) The "P" of PIE documentation.
D) The "R" in DAR documentation.

Dyspnea

Difficulty or discomfort in breathing, often described as shortness of breath.

Wheezing

A high-pitched whistling sound made while breathing, indicating obstruction or narrowing of the respiratory passages.

SOAP Documentation

A systematic method of documentation in healthcare that stands for Subjective, Objective, Assessment, and Plan, guiding clinicians in organizing patient information.

  • Comprehend the significance of precise and thorough documentation in patient care.