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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
MRI
Magnetic Resonance Imaging
26
OTC
Over the Counter
27
PRN
As needed
28
RLQ
Right lower quadrant
29
SOAP
Subjective Objective Assessment Plan
30
ROS
Review of Systems
31
UTI
Urinary Tract Infection
32
WBC
White Blood Cell
33
WNL
Within Normal Limits
34
Name the 12 systems that should be documented in the ROS
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
34
What is the pneumonic used for writing admission orders and what does it stand for?
AD CAVA DIMPLS Admit Diagnosis Condition Activity Vital Signs Allergies Diet Interventions Medications Procedures Labs/diagnostic studies Special instructions
35
ADEs
Adverse Drug Events
36
BMP
Basic Metabolic Panel
37
BR
Bed Rest
38
CAD
Coronary Artery Disease
39
CC
Chief Complaint
40
CMS
Center for Medicare and Medicaid Services
41
CPOE
Computerized Physician Order Entry
42
D5NS
Dextrose 5% Normal Saline
42
CVA
Cerebrovascular Accident
43
ED
Emergency Department
44
EMR
Electronic Medical Record
45
H&H
Hematocrit and hemoglobin
46
HHS
Health and Human Services
47
HR
Heart Rate
48
I&O
Intake & Output
49
ISMP
Institute for Safe Medication Practices
50
IV
Intravenous
51
NPSG
National Patient Safety Goal
52
OCR
Office of Civil Rights
53
PACU
Post Anesthesia Care Unit
54
PCP
Primary Care Provider
55
PRN
As needed
56
RLL
Right lower lobe
57
RR
Respiratory rate
58
S/P
Status Post
59
T
Temperature
60
VS
Vital Signs
61
WNL
Within Normal Limits
62
AMI
Acute Myocardial Infarction
63
AP
Anterior Posterior
64
BP
Blood Pressure
65
BRP
Bathroom Privileges
66
CBC
Complete Blood Count
67
CDSS
Clinical Decision Support System
68
COPD
Chronic Obstructive Pulmonary Disease
69
CT
Computed Tomography
70
CXR
Chest Xray
71
ECG
Electrocardiogram
72
E/M
Evaluation & Management
73
FH
Family History
74
H&P
History and Physical
75
HPI
History of Present Illness
76
HTN
Hypertension
77
IS
Incentive Spirometry
78
IT
Information Technology
79
NPO
Nothing by mouth
80
NS
Normal Saline
81
OOB
Out of Bed
82
PCA
Patient Controlled Analgesia
83
PMH
Past Medical History
84
PT
Physical therapy
85
ROS
Review of Systems
86
SH
Social History
87
SVN
Small volume nebulizer
88
TID
Three times per day
89
WBC
White blood cells

Clin Skills (4 decks)

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