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Clin Skills > Clinical Documentation Ch 11&12 > Flashcards

Clinical Documentation Ch 11&12 Flashcards

1
Q

What are some questions that should be answered daily for a postoperative patient?

A

Pain - controlled? Improving?
Bowel Movement - have they had one? moving gas?
Lines/catheters/devices -removed?
Activity level - change?
Diet - change?

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2
Q

A postoperative patient has been on a full liquid diet for the last 24 hours. He now has bowel sounds and says he is hungry. Write an order for a change in diet.

A

Return of bowel function. Resume regular diet as tolerated.

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3
Q

7 components of a procedure note

A
  1. Name - procedure
  2. Indication
  3. Consent - risk, benefits, complications, name & relationship to pt
  4. Anesthesia
  5. Details- explain procedure and techniques used
  6. Findings - pertinent
  7. Complicatons
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4
Q

List at least 5 components of an operative note.

A
  1. Surgeon
  2. Surgical assistants
  3. Anesthesia - type used & name of who administered
  4. Pre/post op diagnoses
  5. Descriptions - specimens, EBL, drains, etc
  6. Complications
  7. Disposition - of pt at handoff
  8. Name of procedure
  9. Date of procedure
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5
Q

Name at least 3 risks associated with copying and pasting notes.

A
  1. Relaying outdated/inaccurate data in the pt record
  2. Redundant information making it harder to ID current info
  3. Inability to ID author or intent of documentation
  4. Inability to figure out when documentation was created
  5. Pass on false information
  6. Inconsistent notes
  7. Unnecessarily long notes
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6
Q

List the 5 Ws that could be sources of postoperative fever.

A

Wind - respiratory
Wound - infection
Water - UTI
Walk - thrombic event
Wonder drug - side effects/adverse reaction

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7
Q

BMP

A

Basic Metabolic Panel

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8
Q

CBC

A

Complete blood count

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9
Q

EMR

A

Electronic medical record

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10
Q

HD

A

Hospital day

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11
Q

I&O

A

Intake & output

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12
Q

JVD

A

Jugular venous distention

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13
Q

PMH

A

Past medical history

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14
Q

ROS

A

Review of systems

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15
Q

WBC

A

White blood cells

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16
Q

BP

A

Blood pressure

17
Q

EBL

A

Estimated blood loss

18
Q

H&P

A

History and physical

19
Q

HPI

A

History of present illness

20
Q

IS

A

Incentive spirometry

21
Q

PCP

A

Primary care provider

22
Q

POD

A

Postoperative day

23
Q

SOB

A

Shortness of breath

24
Q

Name at least 3 clinical risk factors associated with re-admission within 30 days of discharge.

A
  1. use of anticoagulants
  2. use of narcotics
  3. use of steroids
  4. comorbidities - CHF, renal disease, diabetes, cancer, anemia, weight loss
25
Q

List at least 4 nonclinical risk factors associated with re-admission within 30 days of discharge.

A
  1. lack of support at home i.e financially, socially
  2. Premature discharge
  3. Nonadherence to follow up procedures/instructions
  4. Barriers to learning
  5. Substance abuse
  6. Homelessness
  7. Delay in seeking medical tx
26
Q

List at least 3 components of discharge orders

A
  1. Disposition
  2. Activity level
  3. Diet
  4. Medication reconciliation
  5. Follow up instructions
  6. Notification instructions - s/s that could signal complications
27
Q

List 3 components that should be addressed when instructing patient on activity at time of discharge

A
  1. Specific weight limit
  2. Driving instructions
  3. Restrictions that may affect their occupation
28
Q

List at least 7 components of the discharge summary

A
  1. Date - admission & discharge
  2. Diagnosis - admission & discharge
  3. Physicians - attending, PCP & consult providers
  4. Procedures
  5. History- admission
  6. Hospital course- daily progress and response to txs
  7. Discharge medications & instructions
  8. Condition - discharge
  9. Disposition
29
Q

List at least 3 entities that may ask for the discharge summary

A
  1. Insurance companies
  2. Quality assurance personnel
  3. Members of healthcare team i.e consult providers
30
Q

List at least 3 diagnoses for pts who are most likely to leave the hospital AMA

A
  1. Substance abuse disorders
  2. Family emergencies
  3. Obligations - financial & personal
  4. Feeling bored/fed up/well enough
  5. Unhappy with their tx
31
Q

List at least 3 elements that should be included in an AMA note

A
  1. Pts decision to leave
  2. Witnesses - name & relation
  3. Quotes explaining why pt wants to leave
  4. Discharge instructions/follow-up care
32
Q

AMA

A

Against medical advice

33
Q

H&H

A

Hematocrit & hemoglobin

34
Q

PCP

A

Primary care provider

35
Q

CEA

A

CARCINOembryonic antigen

36
Q

H&P

A

History and physical

Clin Skills (4 decks)

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