142 Final Flashcards
M2: Purposes of a Health Care Record?
- 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
M2: What are the legal and ethical guidelines for documentation?
- 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
M2: What are the different methods for documenting health data?
- Narrative
- Problem Orientated
- Source Records
- Charting by Exception
M2: Define Narrative documentation
- record patient assessment and nursing care provided (story like format to document information)
M2: Define Problem Orientated
- organizing documentation to place primary focus on patients individual problems
M2: Define Source Records
- organized by each discipline (e.g nursing, social work, respiratory therapy)
M2: Define Charting by Exception
-patient meets all standards unless otherwise stated
M2: List acronym for type of Charting
- SOAPIE
M2: List acronym for type of Documentations
- ISBAR
M2: List acronym for type of Notes in other formats
- PIE
- DAR
M2: Define SOAPIE
Subjective Objective Assessment Planning Intervention Evaluation
M2: Define ISBAR
Identification Situation Background Assessment Recommendation
M2: Define PIE and DAR
Problem
Intervention
Evaluation
Data
Action
Response
M2: What are the quality guidelines for documenting and reporting?
- Factual
- Organized
- Current
- Accurate
- Complete
M2: Define Information Technology
Information Technology refers to the management and processing of info, generally with the assistance of computers
M2: Define Health Informatics
Health Informatics is the “intersection of clinical, IM/IT (information management/information technology) and management practices to achieve better health”
M2: Define Clinic Information Systems
Programs including monitoring systems; order entry systems; and laboratory, radiology and pharmacy systems
M3: Describe the Health History Categories
- Identifying Data
- Chief complaint
- Present Illness
- Past medical history
- Personal History
- Family history
- Functional status
- Pain Assessment
M3: What are the differences between a sign and a symptom?
- Sign = objective (nurses notices it)
- Symptom = subjective (patient complaint)
M3: What is the mnemonic of pain assessment and what do they stand for?
Normal Onset Provoking Quality Radiation Severity Treatment Understanding Values
M4: What are the skills required for a physical assessment?
- Inspection
- Palpation
- Auscultation
- Percussion
M5: What are Health care-associated infections (HIA’s)?
- nosocomial infection
- Urinary, Respiratory and Skin
- e.g Clostridium difficile, MRSA, Psuedomonas Pneumonia
M5: Define the Chain of Infection
- Infectious Agent
- Reservoir
- Portal of Exit
- Mode of Transmission
- Portal of Entry
- Host
M5: Define ways of breaking chain of infection
(IA) - (R) - (PoE) - (MoT) - (PoE) - (H) -
