documentation Flashcards
1
Q
a problem oriented medical record
A
uses progress notes that can be shared among the team
2
Q
AC is the abbreviation for
A
before meals
3
Q
NPO is the abbreviation for
A
nothing by mouth
4
Q
ad lib is the abbreviation for
A
at liberty or freely
5
Q
charting by exception (CBE)
A
only chart unexpected findings
6
Q
subjective, objective, assessment, plan (SOAP)
A
used for problem oriented charting
7
Q
NKA abbreviation
A
no known allergies
