Documentation Flashcards
Unit 2
What is are the advantages of Electronic Health Records?
Electronic records allow providers to follow a client’s care from one facility to another, with information being available instantaneously. EHRs also enhance communication between providers. Moreover, with legible documentation, medical and prescription errors are reduced, and more reliable coding and billing can occur.
What are the Expected Components of a Health Record?
demographics, vital signs, medical history, medications, allergies and immunizations,
What are the Advantages of Electronic Documentation Systems?
The providing team could come up with solutions using a more efficient time.
What are the Health Care Professional Roles Regarding Documentation?
HIPAA
What are the Origins of Electronic Health Records (EHRs)?
The first utilization of EHRs emerged in the 1960s. In the 1970s, as computer technology became more accessible, the federal government began using EHRs in the Department of Veteran Affairs. As electronic technology advanced and became more widespread in the 1980s, the use of EHRs increased. In 1997, the Institute of Medicine (IOM) recommended the adoption of EHRs nationwide in its advocacy for safer health care.
Which Documentation Method Only Documents Unexpected Client Findings?
Chart by exception
What are the Components of Documentation Entries?
Depends on the documentation system you are using. The systems used are as followed.
Source-oriented medical records,
Problem-oriented medical records,
Subjective, objective, assessment, and plan charting (SOAP notes),
Problem–intervention–evaluation charting (PIE model),
Focus charting,
Charting by exception (CBE)
What is the PIE model?
Type of documentation that omits the plan of care and utilizes flow sheets and progress notes.
PIE stands for Problem-Intervention-Evaluation charting
What is focus charting and what do you use to write it?
Centers on specific health care problems and the change in condition, client events and concerns. Three items must be documented which are data, action and response (DAR).
What is Problem-Oriented Medical Records? and What are the four components?
is Used to create a comprehensive and organized approach among all members of the interdisciplinary team.
And the FOUR components are A database in which assessment data are documented
A problem list that lists the client’s problem chronologically
An initial plan that outlines goals, expected outcomes, and further data needed, if necessary
Progress notes using the SOAP (subjective, objective, assessment, plan) format
What is Objective Data?
Data OBSERVED by the nurse
What are the Abbreviations on The Joint Commission’s Do Not Use List?
IU (International Unit)
MS
MSO4 and MgSO4
Per os
qd, q.d., Q.D., or QD
qhs
qod, q.o.d., Q.O.D., or QOD
SC, SQ, sub q
TIW or tiw
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
U, u (unit)
What are the Acceptable Situations for a Telephone Prescription?
Verbal prescriptions should be reserved for emergency situations due the potential for error in transcription and omission of safety safeguards that are built into computerized provider order entry systems.
What does a Correctly Written Prescriptions include?
Patient Information,
Date,
Dosage,
Route of Administration,
Frequency,
Quantity,
Refills,
Prescriber Information,
And Special Instructions
What are the Medical Abbreviations?
ABBREVIATION
MEANING
ABD
Abdomen
a.c. or ac
Before meals
Ad lib
At liberty (client can move around freely)
BID or b.i.d.
Twice a day
BK
Below the knee
BP
Blood pressure
cath
Catheter
CBC
Complete blood count
c/o
complains of
CPR
Cardiopulmonary resuscitation
C & S
Culture and sensitivity
CXR
Chest x-ray
DNR
Do not resuscitate
DX
Diagnosis
FBS
Fasting blood sugar
GI
Gastrointestinal
gtt
Drop
H&H
Hemoglobin and hematocrit
HOB
Head of bed
hr
Hour
Hx
History
ICU
Intensive care unit
I&O
Input and output
IV
Intravenous
LLE
Left lower extremity
LMP
Last menstrual period
LOC
Level of consciousness
LUE
Left upper extremity
MI
Myocardial infarction (heart attack)
MRSA
Methicillin-resistant Staphylococcus aureus
NG
Nasogastric
NKA
No known allergies
NKDA
No known drug allergies
NPO
Nothing by mouth
N&V, N/V
Nausea and vomiting
O2
Oxygen
OOB
Out of bed
per
Through or by
PO
By mouth
PRN
As needed
q
Every
r/o
Rule out
Rx
Prescription
Stat
At once, immediately
TID
Three times a day
Tx
Treatment
UA
Urinalysis
Wt
Weight
