charting Flashcards
1
Q
Admission H&P
A
- WHY they must be admitted
- REASON for admission
- normal parts of notes
2
Q
Pre-op note
A
- required before procedures typically done by surgeon
- confirm you’re doing right thing on right patient
- explain procedure; H &P; no change in PMH, Rx & allergies
3
Q
Brief-op note
A
- typically by PA/NP/Resident assisting
- procedure performed, findings
- place holder until final op note is dictated by surgeon (more detailed)
4
Q
Progress note
A
5
Q
Discharge summary
A
- detailed report summarizing duration of patient’s admission
- completed by MDs, sometimes PAs
6
Q
Informed consent
A
7
Q
Admission orders
A
Admit
Diagnosis detailed by ICD-10 code
Condition/Code
Vitals– how often, criteria for alerts/who to alert
Allergies
Activities
Nursing Orders
Diet
IV fluids
Special/Studies– specific to pt and admission dx (consults, imaging,etc)
Meds– 6Ps
Labs
ADC VAAN DISML
8
Q
Pre-op orders
A
- code status
- pt monitoring
- diet– strict NPO
- fluids
- activity
- preop abx
- IV pain meds only & antiemetics
- labs/imaging
- consent
- additional: blood products, reversals, held meds, DVT prophylaxis
9
Q
Post-op orders
A
- diet
- daily labs
- alerts about vitals
- abx
- IV and PO pain meds
- antiemetics– zofran, reglan, phenergen suppository
- prophylaxis
- home meds PRN
10
Q
Discharge orders
A
- when and where
- transportation
- meds
- instructions
11
Q
IV fluid that replaces insensible fluid loss
A
maintenace fluids
12
Q
IV fluids that corrects the body’s fluid deficit
A
replacement fluids– surgery, gastric/bowel drainage, vomiting, diarrhea, trauma, burns, third spacing
13
Q
- Aqueous solutions with mineral salts or other water soluble molecules
- water can freely float btwn intravascular and intracellular spaces
- EX: NS, LR, D5 1/2 NS + 20mEq KCL at 125ml/hr
A
crystalloids
14
Q
- Solutions with large molecular weight substances that aim to keep fluid (H2O) where it is, or pull it back towards it
- Ex: albumin, blood
A
colloids
15
Q
what are the 6Ps of medication in admission orders
A
Pain, Pillow, Poop, Pus, Previous, Prophylaxis
