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Monday 1155 Lecture > 1165 THURS Week 4 Lecture: Documenting And Reporting > Flashcards

1165 THURS Week 4 Lecture: Documenting And Reporting Flashcards

1
Q

Charting by exception

A

is a system for documenting exceptions to normal illness or disease progression, using a shorthand method of charting what’s usual and normal

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2
Q

Critical care pathway

A

multidisciplinary plan that outlines the expected course of care for patients with a specific medical condition or undergoing a particular procedure.

DESIGNED TO STREAMLINE RECOVERY

The pathway includes key interventions, activities, and milestones to guide healthcare providers in delivering efficient and effective care.

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3
Q

primary documents communicating a patient’s care plan to the post-hospital care team.

A

Discharge summary

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4
Q

An _________is an electronic version of a patients medical history, that is maintained by the provider over time

A

Electronic Health Record (EHR)

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5
Q

_______ is simply a one- or two-page form that gathers all the important data regarding a patient’s condition, in this case diabetes.

The _____ housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met.

A

flow sheet

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6
Q

documentation method that concentrates on specific, pertinent information related to a particular aspect of a patient’s care.

Concise / targeted approach to recording patient data, emphasizing the essential details, treatment, or response to interventions.

A

Focus charting

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7
Q

Graphic Record

A

visual representation of a patient’s vital signs, treatments, assessments, or other relevant information over a specific period.

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8
Q

Health Information Exchange (HIE)

A

Electronic sharing of patient health information among different healthcare providers and systems.

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9
Q

Used in Handoffs, transfers, or when escalating patient care.

Introduction:
Identify yourself and your role.

Situation: with patient

Background of patient

Assessment of patient

Recommendation: to be done with patient

A

ISBAR

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10
Q

a _______(MDS) refers to a standardized set of essential information that is systematically collected and maintained for every patient

A

Minimum Data Set

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11
Q

Documentation where nurses record information about a patient’s care and condition in a paragraph format.

Unlike structured forms or checklists

A

Narrative notes

More descriptive than checklist notes

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12
Q

This type of charting focuses on recording details surrounding unusual incidents, deviations from the expected course of care, or any noteworthy events that may impact the patient’s well-being

A

Occurrence chartinf

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13
Q

Outcome and Assessment Information Set (OASIS) is….

A

a standardized data set used in home health care to assess and measure patient outcomes.

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14
Q

A _____(PHR) in nursing refers to a health information document that is maintained and managed by an individual patient,

Unlike the traditional medical record, which is created and maintained by healthcare providers

A

Patient health record

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15
Q

PIE charting

A

Problem, Intervention, and Evaluation charting

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16
Q

Progress notes in nursing are written or electronic documents that provide a detailed, chronological account of a patient’s care, treatment, and response to interventions during a specific period

Usually in this format

A

Subjective
Objective
Assessment
Plan

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17
Q

Purposeful rounding in nursing…

A

systematic and intentional approach to regularly checking on patients to ensure their needs are met and to proactively address any potential issues.

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18
Q

Read-back in nursing….

A

Repeating back what was said to you to ensure correct communication

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19
Q

Actividades

AMB

A

Ambulatory

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20
Q

Actividades

BRP

A

Bathroom Privileges

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21
Q

Actividades

CBR

A

Complete Bed rest

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22
Q

Actividades

OOB

A

Out of bed

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23
Q

Actividades

up ad lib

A

Up as desired

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24
Q

Assessment Data

abd

A

Abdomen

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25
Q

Assessment Data

BP

A

Blood pressure

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26
Q

Assessment Data

bx

A

Biopsy

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27
Q

Assessment Data

c/o

A

Complaints of

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28
Q

Assessment Data

CTA

A

Clear to ausculation

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29
Q

Assessment Data

dx

A

Diagnosis

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30
Q

Assessment Data

FUO

A

Fever unknown orign

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31
Q

Assessment Data

GI / GU

A

Gastrointestinal

Gastrourinary

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32
Q

Assessment Data

H/A

A

Headache

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33
Q

Assessment Data

h/o

A

History of

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34
Q

Assessment Data

HPI

A

History of Present Illness

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35
Q

Assessment Data

Imp

A

Impressions

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36
Q

Assessment Data

lt or L with a circle around it

A

Left

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37
Q

Assessment Data

MAE

A

Moves all extremeities

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38
Q

Assessment Data

NAD

A

No apparent distress

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39
Q

Assessment Data

NKA

A

No known allergies

40
Q

Assessment Data

N/ V

A

Nausea/ vomiting

41
Q

Assessment Data

neg

42
Q

Assessment Data

P

43
Q

Assessment Data

PE

A

Physical Examination

44
Q

Assessment Data

PMH

A

Past Medical History

45
Q

Assessment Data

R

A

Respirations

46
Q

Assessment Data

R/O

47
Q

Assessment Data

ROS

A

Review of systems

48
Q

Assessment Data

rt or r with a circle

49
Q

Assessment Data
SOB

A

Shortness of breath

50
Q

Diseases

ASCVD

A

Arteriosclerotic cardiovascular disease

51
Q

Diseases

ASHD

A

Arteriosclerotic heart disease

52
Q

Diseases

BPH

A

Benign prostatic hypertrophy

53
Q

Diseases
CA

54
Q

Diseases
CAD

A

Coronary Artery Disease

55
Q

Diseases
CHF

A

Congestive Heart Failure

56
Q

Diseases
COPD

A

Chronic Obstructuve Pulmonary Disease

57
Q

Diseases
CVA

A

Cerebrovascular Accident

58
Q

Diseases
DM

A

Diabetes mellitus

59
Q

Diseases

HTN

A

Hypertension

60
Q

Diseases

PE

A

Pulmonary Emboli

61
Q

Diseases

PVD

A

Peripheral vascular disease

62
Q

Diseases
URI

A

Upper respitory infections

63
Q

Diagnostic Studies

ABG

A

Arterial Blood Gas

64
Q

Diagnostic Studies

BE

A

Barium enema

radiographic (X-ray) examination of the lower gastrointestinal (GI) tract

65
Q

Diagnostic Studies

C&S

A

Culture and Studies

66
Q

Diagnostic Studies

CXR

A

Chest xray

67
Q

Miscellaneous

AMA

A

Against medical advice

68
Q

Miscellaneous

BSD

A

Bedside drainage

69
Q

Miscellaneous
Dsg

70
Q

Miscellaneous
FOB & HOB

A

Foot of bed
Head of bed

71
Q

Miscellaneous
Fx

72
Q

Miscellaneous
Hx

73
Q

Miscellaneous
NS

A

Normal Saline

74
Q

Miscellaneous
RX

75
Q

Miscellaneous

pt

76
Q

Miscellaneous

S/P

A

Status Post

77
Q

Miscellaneous
TF

A

Tube feeding

78
Q

Miscellaneous
TPR

A

Temperature, Pulse, Respiration

79
Q

Miscellaneous
TX

80
Q

Miscellaneous
VS

A

Vital sign

81
Q

Miscellaneous
WA

A

While awake

82
Q

Avoid asking which type of questions

A

Why, questions

83
Q

Don’t use “cc” use ____

84
Q

Don’t use SC, SQ, sub q, instead use

A

Subcutaneously or subcut

85
Q

True or False

Use Trailing Zeros after a decmil place

Exp. 1.0 mg

A

False.

Don’t use trailing zeros after a numbe4

1mg

Correct way to write it

86
Q

Don’t use a Naked Decmil Point

.5 mg is incorrect

0.5 mg is correct

True or False

87
Q

Write mg. & ml. With a period after
True or false

A

False

mg & mL

Correct ways to write this

88
Q

Use commas when writing a numbe4 at or above 1,000

True or False

89
Q

(MDI) is a small device that delivers a measured amount of medication to your lungs

A

metered dose inhaler

90
Q

(DPI) is an asthma treatment option for older kids and teens.

A

dry powdered inhaler

91
Q

ABG

pH

A

7.35 - 7.45

92
Q

ABG

PaCO²

93
Q

ABG

SaO²

Saturation of Oxygen

94
Q

ABG

PaO²

A

75 - 100 mmHg

95
Q

ABG

Bicarbonate HCO3

A

22 - 26 mEq/L

Monday 1155 Lecture (8 decks)

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