EMR

Question 1

Each letter of FACT charting

Answer 1

Factual
Accurate
Complete
Timely

Question 2

CPOE

Answer 2

Computerized Provider Order Entry

Question 3

ABD

Answer 3

Abdomen

Question 4

a.c.

Answer 4

Before meals

Question 5

Ad lib

Answer 5

At liberty (client can move around freely)

Question 6

BID

Answer 6

Twice a day

Question 7

BK

Answer 7

Below knee

Question 8

Cath

Answer 8

Catheter

Question 9

CBC

Answer 9

Complete blood count

Question 10

c/o

Answer 10

Complains of

Question 11

C & S

Answer 11

Cultural sensitivity

Question 12

Dx

Answer 12

Diagnosis

Question 13

FBS

Answer 13

Fasting blood sugar

Question 14

gtt

Answer 14

drop

Question 15

H&H

Answer 15

Hemoglobin & hematocrit

Question 16

Hx

Answer 16

History

Question 17

I&O

Answer 17

Input & output

Question 18

LMP

Answer 18

last menstrual period

Question 19

LOC

Answer 19

Level of consiousness

Question 20

NKA

Answer 20

No known allergies

Question 21

NPO

Answer 21

Nothing by mouth

Question 22

OOB

Answer 22

Out of bed

Question 23

PRN

Answer 23

As needed

Question 24

q

Answer 24

Every

Question 25

Rx

Answer 25

Prescription

Question 26

Tx

Answer 26

Treatment

Question 27

TID

Answer 27

3 times a day

Question 28

UA

Answer 28

Urinalysis

Question 29

When can telephone prescriptions be accepted?

Answer 29

Only in emergency situations

Question 30

Which agency advocates for nationwide use of EMRs?

Answer 30

The Institute of Medicine

Question 31

Source- Orientated medical record

Answer 31

Traditional form of documentation (rarely used today)

Question 32

Which type of documentation uses SOAP for notes?

Answer 32

POMR – Problem-oriented medical record

Question 33

What does SOAP stand for?

Answer 33

Subjective
Objective
Assessment
Plan

Question 34

What does PIE stand for?

Answer 34

Problems
Interventions
Evaluations

Question 35

Which type of documentation uses DAR?

Answer 35

Focus charting

Question 36

What does DAR stand for?

Answer 36

Data
Action
Response

Question 37

5 advantages of electronic documentation.

Answer 37

Real time access to client record.

Built in clinical alerts (for i.e. contraindications)

Increased coordination of care

Allow client-provider interaction

Question 38

Write ___ instead of IU

Answer 38

International unit

Question 39

Write ___ instead of MS MSO4

Answer 39

Morphine sulfate

Question 40

Write ___ instead of per os

Answer 40

PO/by mouth

Question 41

Write ___ instead of qd

Answer 41

Daily

Question 42

Write ___ instead of qhs

Answer 42

Nightly

Question 43

Write ___ instead of qod

Answer 43

every other day

Question 44

Write ___ instead of SC

Answer 44

Subcut

Question 45

Write ___ instead of TIW

Answer 45

three times weekly

Question 46

Write ___ instead of U

Answer 46

unit

Question 47

In what situations (2) is it acceptable to repeat back a verbal prescription without writing it down first?

Answer 47

Emergency

Sterile environment