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Clin Skills > Clinical Documentation Ch 3 & 10 > Flashcards

Clinical Documentation Ch 3 & 10 Flashcards

1
Q

7 cardinal aspects of the HPI that should be documented in the Subjective Information

A

Location
Onset
Character
Associated s/s
Timing
Exacerbating/relieving factors
Severity

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2
Q

Name pertinent aspects of the PMH that should be documented

A

past Dx’s, surgeries/hospitalizations, medications, allergies, health maintenance/immunizations

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3
Q

What information about the patient’s social history would be important to document?

A

Smoking hx, drinking hx, occupation, lifestyle, ability to access healthcare, nutritional info, sexual orientation, recent travel, if lived abroad, gender identification, etc

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4
Q

Name 5 things that would be documented as subjective information

A
  1. History obtained from spouse
  2. Family Hx
  3. ROS
  4. Medications
  5. Onset of CC
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5
Q

Name 5 things that would documented in the Plan portion of the HPI

A
  1. Patient education
  2. Lab and Xray orders
  3. Recommended OTC medications
  4. Follow-up instructions
  5. Referrals
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6
Q

BMP

A

Basic Metabolic Panel

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7
Q

CC

A

Chief Complaint

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8
Q

EMR

A

Electronic Medical Record

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9
Q

GI

A

Gastrointestinal

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10
Q

H&P

A

History and Physical

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11
Q

Hct

A

Hematocrit

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12
Q

Hgb

A

Hemoglobin

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13
Q

ICD-10

A

International Classification of Diseases-10th Revision

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14
Q

OB/GYN

A

Obestetrics/Gynecology

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15
Q

PMH

A

Past Medical History

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16
Q

RICE

A

Rest, ICE, Compression, Elevate

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17
Q

SH

A

Social History

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18
Q

UA

A

Urine Analysis

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19
Q

VS

A

Vital Signs

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20
Q

CBC

A

Complete Blood Count

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21
Q

DDX

A

Differential Diagnosis

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22
Q

FH

A

Family History

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23
Q

GYN

A

Gynecology

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24
Q

HPI

A

History of Present Illness

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25
Q

MRI

A

Magnetic Resonance Imaging

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26
Q

OTC

A

Over the Counter

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27
Q

PRN

A

As needed

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28
Q

RLQ

A

Right lower quadrant

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29
Q

SOAP

A

Subjective Objective Assessment Plan

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30
Q

ROS

A

Review of Systems

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31
Q

UTI

A

Urinary Tract Infection

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32
Q

WBC

A

White Blood Cell

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33
Q

WNL

A

Within Normal Limits

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34
Q

Name the 12 systems that should be documented in the ROS

A
  1. HEENT
  2. Cardiovascular
  3. Respiratory
  4. Gastrointestinal
  5. Genitourinary
  6. Musculoskeletal
  7. Integumentary
  8. Neurological
  9. Psychiatric
  10. Endocrine
  11. Hematologic/lymphatic
  12. Allergic/immunologic
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34
Q

What is the pneumonic used for writing admission orders and what does it stand for?

A

AD CAVA DIMPLS
Admit
Diagnosis
Condition
Activity
Vital Signs
Allergies
Diet
Interventions
Medications
Procedures
Labs/diagnostic studies
Special instructions

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35
Q

ADEs

A

Adverse Drug Events

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36
Q

BMP

A

Basic Metabolic Panel

37
Q

BR

38
Q

CAD

A

Coronary Artery Disease

39
Q

CC

A

Chief Complaint

40
Q

CMS

A

Center for Medicare and Medicaid Services

41
Q

CPOE

A

Computerized Physician Order Entry

42
Q

D5NS

A

Dextrose 5% Normal Saline

42
Q

CVA

A

Cerebrovascular Accident

43
Q

ED

A

Emergency Department

44
Q

EMR

A

Electronic Medical Record

45
Q

H&H

A

Hematocrit and hemoglobin

46
Q

HHS

A

Health and Human Services

47
Q

HR

A

Heart Rate

48
Q

I&O

A

Intake & Output

49
Q

ISMP

A

Institute for Safe Medication Practices

50
Q

IV

A

Intravenous

51
Q

NPSG

A

National Patient Safety Goal

52
Q

OCR

A

Office of Civil Rights

53
Q

PACU

A

Post Anesthesia Care Unit

54
Q

PCP

A

Primary Care Provider

55
Q

PRN

56
Q

RLL

A

Right lower lobe

57
Q

RR

A

Respiratory rate

58
Q

S/P

A

Status Post

59
Q

T

A

Temperature

60
Q

VS

A

Vital Signs

61
Q

WNL

A

Within Normal Limits

62
Q

AMI

A

Acute Myocardial Infarction

63
Q

AP

A

Anterior Posterior

64
Q

BP

A

Blood Pressure

65
Q

BRP

A

Bathroom Privileges

66
Q

CBC

A

Complete Blood Count

67
Q

CDSS

A

Clinical Decision Support System

68
Q

COPD

A

Chronic Obstructive Pulmonary Disease

69
Q

CT

A

Computed Tomography

70
Q

CXR

A

Chest Xray

71
Q

ECG

A

Electrocardiogram

72
Q

E/M

A

Evaluation & Management

73
Q

FH

A

Family History

74
Q

H&P

A

History and Physical

75
Q

HPI

A

History of Present Illness

76
Q

HTN

A

Hypertension

77
Q

IS

A

Incentive Spirometry

78
Q

IT

A

Information Technology

79
Q

NPO

A

Nothing by mouth

80
Q

NS

A

Normal Saline

81
Q

OOB

A

Out of Bed

82
Q

PCA

A

Patient Controlled Analgesia

83
Q

PMH

A

Past Medical History

84
Q

PT

A

Physical therapy

85
Q

ROS

A

Review of Systems

86
Q

SH

A

Social History

87
Q

SVN

A

Small volume nebulizer

88
Q

TID

A

Three times per day

89
Q

WBC

A

White blood cells

Clin Skills (4 decks)

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