CH 7 Flashcards
An electronic version of a person’s medical record is _________; also called electronic medical record.
Electronic Health Record
Another term for medical record is ______.
Clinical Record
At or toward the front of the body or body part is ventral or _______.
Anterior
A ____ is a word element placed after a root; it changes the meaning of the word.
Prefix
At the side of the body or body part is ______.
Lateral
An ______ is a shortened form of a word or phrase.
Abbreviation
A part of a word us a _____.
Word Element
A _____ is a type of card file that summarizes information found in the medical record.
Kardex
The medical record is also called the _____.
Chart
The part nearest to the center or the point of origin is _______.
Medial
_______ is the exchange of information- a message sent is receive and interpreted by the intended person.
Communication
Another term for anterior is ______.
Ventral
A written account of a person’s condition and response to treatment and care is the chart or _______.
Recording
______ is at or toward the back of the body or body part; posterior.
Dorsal
The oral account of care and observations is ______.
Reporting
_____ is the part farthest from the center or from the point of attachment.
Distal
A word element placed before a root is the ____. It changes the meaning of the word.
Prefix
A word element containing the basic meaning of the word is the ______.
Root
Another word for dorsal is ______.
Posterior
_____ is the written account of care and observation.
Recording
_____ is at or near the muddle or mid-line of the body or body part.
Medial
_______ describes the care given and the person’s response and progress.
Progress Note
Another name for an electronic health record is __________.
Electronic Medical Record
A report that the nurse gives at the end of the shift to the on-coming staff is __________.
End of Shift Report
When health team members communicate, they share all of this information except?
Gossip about the person and his family
A nursing assistant tells the nurse that Mrs. Jones ate a small amount of his lunch. The nurse what?
Asks for further informaton because words may have different meanings to different people.
When giving information to another health team member is what?
Be brief and concise to reduce omitting important details
The medical record or chart is?
A permanent legal document
Which of these is not included in the person’s chart?
The daily menu
A nursing assistant must know what?
Must know the agency policy before reading the chart
If a person asks to see his or her record, the nursing assistant reports what?
The request to the nurse
The admission record contains what?
The name, birth date, age, and gender of the person
The health history is completed when?
The person is admitted
The nurse records the person’s reason for seeking health care in the what?
Health history
Vital signs taken every shift are recording in the what?
Graphic sheet
In long-term care, OBRA requires a written summary of the person when?
Every 3 months
A weekly care record that has boxes for each day of the week is used in what?
Home care
What is the Kardex?
A quick, easy source of information about the person
The nursing assistant reports information about the person when?
There is a change in the person’s condition
During the end-of-shift report, call lights, care, and routine tasks are usually done by who?
By the staff going off duty
The general rules for recording include all of these except?
Use ditto marks needed
If you are recording using the 24-hour clock, which of these is correct?
1300
I a person points to the left side of his body below the umbilicus and tells you he has pain, you will tell the nurse he has pain in the what?
Left lower quadrant
When describing the position of body parts, the hands and fingers are what?
Distal
When you are given a computer password, what should you do?
You should never tell anyone your password
The agency computers should not be used to what?
Send e-mails that require immediate reporting
Privacy is protected when you what?
Prevent others from seeing what is on the screen
When you answer the telephone, do not put the caller on hold if what?
The person has an emergency
When you answer a phone when giving home care you should what?
Simply answer with “Hello”
Slow heart rate
Bradycardia
Difficulty urinating
Dysuria
Blue color or condition
Cyanosis
Rapid breathing
Tachypnea
Opening into the trachea
Tracheostome
Inflammation of kidneys
Nephritis
Joint examination with a scope
Arthroscope
Pertaining to blue coloration
Cyanotic
Study of the skin
Dermatology
Incision into large intestine
Colostomy
Instrument used to examine bronchi
Colostomy
Inflammation of the tongue
Glossitis
Nerve pain
Neuralgia
Examination of rectum with instrument
Proctoscopy
Excision of gallbladder
Cholecystectomy
Excision of ovary
Oophorectomy
Incision into stomach
Gastrostomy
Inflammation of stomach
Gastritis
Inflammation of intestine
Enteritis
ADL
Activities of Daily Living
CBC
Complete Blood Count
FBS
Fasting Blood Sugar
LOC
Level of Consciousness
ROM
Range of Motion
