Chapter 17 Flashcards
The act of recording patient status and care?
Documentation
What are the four C’s of documenting?
Clear, concise, correct, complete
____ _____ is used to determinate whether the medical treatments and interventions were necessary and appropriate.
Utilization review
A system of charting in which you only document significant findings or exceptions to standards and norms of care.
Charting by exception
Type of chart entry that tells the story of the client’s experience in the order that it happens
Narrative chart entry
When you are only charting things outside of normal limits?
Charting by exception
BM
bowel movement
BR
bed rest
c/o
complaint of
D&C
Dilation and Curettage
DM
diabetes militus
EBL
estimated blood loss
EENT
ears, eyes, nose, throat
AKA
above knee amputation
Amt
amount
BRP
bathroom privelages
CVA
Cerebrovascular accident (stroke)
dsg
dressing
ETOH
alcohol
FBS
fasting blood sugar
GYN
gynecology
GU
Genitourinary
HA
headache
HTN
hypertension
LMP
last menstrual period
MN
midnight
NAS
no added salt
OOB
out of bed
R/O
rule out
SCD
sequential compression device
SSE
soapsuds enema
TO
telephone order
TPR
temperature, pulse, respirations
w/c
wheelchair
WNL
within normal limits
TB
tuberculosis
s-
without
qam
every morning
