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142 Final Flashcards

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1
Q

M2: Purposes of a Health Care Record?

A
  • facilitates accurate communication
  • provides legal record of care given
  • facilitates funding and resource management
  • allows for auditing, monitoring and evaluation of care-provided
  • serve as research data an learning resources for nursing and health care education
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2
Q

M2: What are the legal and ethical guidelines for documentation?

A
  • no personal opinions
  • correct errors promptly
  • record all facts
  • record in a timely manner
  • record clarification on questions asked by patient
  • document only for yourself
  • avoid generalizations
  • begin entry with date and time
  • end with signature and credentials
  • avoid ‘pre-charting’
  • protect personal access codes
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3
Q

M2: What are the different methods for documenting health data?

A
  • Narrative
  • Problem Orientated
  • Source Records
  • Charting by Exception
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4
Q

M2: Define Narrative documentation

A
  • record patient assessment and nursing care provided (story like format to document information)
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5
Q

M2: Define Problem Orientated

A
  • organizing documentation to place primary focus on patients individual problems
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6
Q

M2: Define Source Records

A
  • organized by each discipline (e.g nursing, social work, respiratory therapy)
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7
Q

M2: Define Charting by Exception

A

-patient meets all standards unless otherwise stated

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8
Q

M2: List acronym for type of Charting

A
  • SOAPIE
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9
Q

M2: List acronym for type of Documentations

A
  • ISBAR
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10
Q

M2: List acronym for type of Notes in other formats

A
  • PIE

- DAR

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11
Q

M2: Define SOAPIE

A 
Subjective 
Objective 
Assessment 
Planning 
Intervention 
Evaluation
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12
Q

M2: Define ISBAR

A 
Identification 
Situation 
Background 
Assessment 
Recommendation
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13
Q

M2: Define PIE and DAR

A

Problem
Intervention
Evaluation

Data
Action
Response

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14
Q

M2: What are the quality guidelines for documenting and reporting?

A
  • Factual
  • Organized
  • Current
  • Accurate
  • Complete
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15
Q

M2: Define Information Technology

A

Information Technology refers to the management and processing of info, generally with the assistance of computers

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16
Q

M2: Define Health Informatics

A

Health Informatics is the “intersection of clinical, IM/IT (information management/information technology) and management practices to achieve better health”

17
Q

M2: Define Clinic Information Systems

A

Programs including monitoring systems; order entry systems; and laboratory, radiology and pharmacy systems

18
Q

M3: Describe the Health History Categories

A
  • Identifying Data
  • Chief complaint
  • Present Illness
  • Past medical history
  • Personal History
  • Family history
  • Functional status
  • Pain Assessment
19
Q

M3: What are the differences between a sign and a symptom?

A
  • Sign = objective (nurses notices it)

- Symptom = subjective (patient complaint)

20
Q

M3: What is the mnemonic of pain assessment and what do they stand for?

A 
Normal
Onset
Provoking
Quality
Radiation
Severity
Treatment
Understanding
Values
21
Q

M4: What are the skills required for a physical assessment?

A
  • Inspection
  • Palpation
  • Auscultation
  • Percussion
22
Q

M5: What are Health care-associated infections (HIA’s)?

A
  • nosocomial infection
  • Urinary, Respiratory and Skin
  • e.g Clostridium difficile, MRSA, Psuedomonas Pneumonia
23
Q

M5: Define the Chain of Infection

A
  • Infectious Agent
  • Reservoir
  • Portal of Exit
  • Mode of Transmission
  • Portal of Entry
  • Host
24
Q

M5: Define ways of breaking chain of infection

A 
(IA) - 
(R) - 
(PoE) - 
(MoT) - 
(PoE) - 
(H) -
25
Q

M5: What is the most important form of practice of asepsis?

A
  • hand washing
26
Q

M5: Define asepsis and aseptic techniques

A

Asepsis - process of keeping away disease-producing micro-organisms
Aseptic Techniques -
- (medical) hand-hygiene and clean gloves and clean
- (surgical) procedures to eliminate ALL micro-organisms

27
Q

M5: What are the components of STABLE

A 
S - maintain Spine curvature 
T - avoid Trunk-twisting 
A - keep your Arms close 
B - use a wide Base 
L - use your Legs 
E - Evaluate the load
28
Q

M6: What are the vital signs?

A
  • 02 Saturation
  • Temperature
  • Pulse
  • Respiration rate
  • Blood Pressure
29
Q

M6: What are the normal ranges for each Vital Sign?

A
  • 95% 02 Sat.
  • 37* C
  • 60-100 bpm
  • 10-20 rpm
  • 120-129 mmHg systolic/80-89 mmHg diastolic
30
Q

M6: What affects the vital signs

A
  • age
  • exercise
  • circadian rhythm
  • stress
  • environment
  • temperature alterations
  • anxiety
  • medications
  • body position
  • smoking
  • acute pain
  • gender
  • ethnicity

Nursing (5 decks)

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