Chapter 4 Flashcards
Abbreviation
A shortened form of a word or phrase
Chart
See ‘’ medical record ‘’
Communication
The exchange of information - a message sent is received and correctly interpreted by the intended person
Conflict
A clash between opposing interests or ideas
Diagnosis
The term used when symptoms, signs, or reasons for a problem are identified
Kardex
A type of card file that summarizes information found in the medical record - medications, treatments, diagnoses, routine care measures, equipment, and special needs
Medical record
A written or electronic document of a person’s condition and response to treatment and care; often referred to as a chart or clinical record
Prefix
A word element placed before a root; it changes the meaning of the word
Progress note
A written description of the care given and the person’s response and progress
Recording
The written account of care and observations; charting
Reporting
The oral account of care and observations
Root
A word element that contains the basic meaning of the word
Suffix
A word element placed after a root; it changes the meaning of the word
Word element
A part of the word
Information about the person’s advance directions would be found in the
a. Admission sheet ( face sheet )
b. Graphic sheet
c. Lab results
d. Flow sheet
a. Admission sheet ( face sheet )
Which of the following would not be found on the activities of the daily living ( ADL ) flow sheet?
a. Hygiene measures
b. Food and fluid intake
c. Lab results
d. Elimination
c. Lab results
Under OBRA residents have the right to
a. Know the information in their medical record
b. Record in their medical record
c. Remove pages from their medical record
d. View the records of other residents
a. Know the information in their medical record
OBRA requires that summaries of care ( progress notes ) be written at least
a. Every month
b. Every other month
c. Every 3 months
d. Every year
c. Every 3 months
To communicate, you should do the following except
a. Use terms with many meanings
b. Be brief and concise
c. Present information logically and in sequence
d. Give facts and be specific
a. Use terms with many meanings
Mr. Drake is discharged from the center. His medical record is
a. Destroyed
b. Sent home with him
c. Permanent
d. Stored on a computer
c. Permanent
These statements are about medical records. Which is false?
a. These are used to communicate information about residents
b. They are a written or electronic account of illness and response to treatment
c. They can be used as evidence of the care giver
d. Anyone working in the center can read them
d. Anyone working in the center can read them
A person is weighed daily. The measurement is recorded on the
a. Admission sheet
b. Kardex
c. Flow sheet
d. Progress notes
c. Flow sheet
Where does the nurse describe the nursing care given?
a. Admission sheet
b. Activities of daily living flow sheet
c. Progress notes
d. Kardes
c. Progress notes
When recording, you do the following except
a. Use ink
b. Include the date and time
c. Erase errors
d. Sign all entries with your name and title
c. Erase errors
These statements are about recording. Which is false?
a. Use the person’s exact words when possible
b. Record only what you did and observe
c. Sign your initials to a mistaken entry
d. Chart a procedure before completing it
d. Chart a procedure before completing it
In the evening the clock shows 9:26. In 24 - hour clock time this is
a. 9:25
b. 1926
c. 0926
d. 2136
d. 2136
A suffix is
a. Placed at the beginning of a word
b. Placed after a root
c. A shortened form of a word or phrase
d. The main meaning of the word
b. Placed after a root
Which term relates to the side of the body?
a. Anterior
b. Lateral
c. Posterior
d. Prosiminal
b. Lateral
These statements are about computers in health care. Which is false?
a. Computers are used to collect, send, record, and store information
b. The person’s privacy must be protected
c. All employees have the same password
d. Computers link one department to another
c. All employees have the same password
You have access to the center’s computer. Which is true?
a. Email and messages are sent only to those needing the information
b. Email is used for reports the nurse needs at once
c. You can open another person’s email
d. You can use the computer for your personal needs
a. Email and messages are sent only to those needing the information
You answer a person’s phone. How should you answer?
a. ‘’ Good morning. Mrs. Parks room. ‘’
b. “ Good morning. Third floor. “
c. “ Hello “
d. “ Good morning. Tammy Brown, nursing assistant, speaking. “
d. “ Good morning. Tammy Brown, nursing assistant, speaking. “
A coworker is often late for work. This means extra work for you. To resolve the conflict, you should do the following except
a. Explain the problem to your supervisor
b. Discuss the matter during the end - of - shift report
c. Give facts and specific behaviors
d. Suggest ways to solve the problem
b. Discuss the matter during the end - of - shift report
