EXAM 1 Flashcards
Reporting
oral communication about a patients status
Documentation
The act of recording patient status and care in written or electronic form, or in combination of the 2 forms
medical record/ health record
historically, the collection of documentation, orders, and other care information for a patient
Clear complete and accurate documentation in a clients health record serves a variety of purposes
communication
legal record
continuity of care
quality improvement
health record system
the overall process by which all patient records are created, stored, and retrieved in an organization
Source-oriented system
members of each discipline record their findings in a separately labeled section of the chart
Problem-oriented records (PROs)
organized around the patient’s problems
Charting by exception
a system of charting in which only significant findings or exceptions to standards and norms of care are charted
Advantages of electronic records systems
Enhanced communication and collaboration among healthcare providers Improved access to information Time savings Improved quality of care Information is private and safe
Disadvantages of electronic health records
Expense
Downtime
Lack of integration
Difficulties associated with change
ADLs
Activities of Daily Living
ad lib
As desired, if the patient desires
AKA
Above-knee amputation
Amb
Ambulation, ambulatory
Amt
Amount
bid
twice a day
BM
bowel movement
BR
bedrest
BRP
bathroom privileges
BSC
bedside commode
c
calories
cath
catheter
CBC
complete blood count
CCU
critical care unit
coronary care unti
c/o
complaint of
CO2
carbon dioxide
CPR
cardiopulmonary resuscitation
CVA
cerebrovascular accident (stroke)
D&C
dilation and curettage
DM
diabetes mellitus
dsg or drsg
dressing
DX or Dx
diagnosis
EBL
estimated blood loss
ECG/EKG
electrocardiogram
ED/ER
emergency department
emergency room
EEG
electroencephalogram
EENT
eyes, ears, nose, throat
ETOH
alcohol
F
female
FBS
fasting blood sugar
Ft
foot
Fx
fracture
GI
gastrointestinal
gtt(s)
Drop(s)
GU
genitourinary
HA
headache
HMO
health maintenance organization
h/o
history of
hob or HOB
head of bed
HOH
hard of hearing
H&P
history and physical
hr
hour
ht
height
HTN
hypertension
hyper
above or high
hypo
below or low
ICU
intensive care unit
I&O
intake and output
lsol
Isolation
IV
Intravenous
IVP
intravenous push
L
liter
lb
pound
LMP
last menstrual period
LPN
licensed practical nurse
LVN
Licensed vocational nurse
mcg
microgram
mL
milliliter
MN
midnight
NAS
no added salt
N/V/D
nausea, vomiting, diarrhea
NKA or NKDA
no known allergies or no known drug allergies
NG
nasogastric
NGT
nasogastric tube
noc
at night
NPO
nothing by mouth
O2
oxygen
OB
obstetrics
OOB
out of bed
OPD
outpatient dept
ortho
orthopedics
OR
operating room
os
mouth
opening
OT
occupational therapy
oz
ounce
pc
after meals
PCA
patient controlled analgesia
PO
by mouth
P
after
PPBS
postprandial blood sugar
prn
as needed
Pt
patient
PT
physical therapy
q
every
qam
every morning
qh
every hour
qid
four times a day
RN
registered nurse
RX or Rx
treatment or perscription
SCD
sequential compression device
SOB
short of breath
SSE
soapsuds enema
STAT
immediately
STI or STD
sexually transmitted infection
sexually transmitted disease
TB
tuberculossi
TO
telephone order
TPR
temperature
pulse
respiration
tid
three times a day
VO
verbal order
VS
vital signs
WBC
white blood count
w/c
wheelchair
WNL
within normal limits
wt
weight
narrative entry chart
tells the story of the patients experience in a chronologica format
problem-intervention-evaluation (PIE)
system that organizes information according to the patients problems and requires keeping a daily assessment record and progress note.
SOAP/SOAPIE/SOAPIER
S- subjective data- what the patient or family members tell you
O- objective data- factual , measurable clinical findings
A- assessment- conclusions drawn from the subjective data
P- Short-term and long-term goals and strategies
I- interventions- Actions of the healthcare team
E- evaluation- an analysis of the effectiveness of interventions
R- revision- changes made to the original care plan
Focus charting
uses assessment data to evaluate client care concerns, problems, or strengths
DAR
data
action
response
FACT system
Flow sheets
Assessment
Concise
Timely
discharge summary
the last entry made in the paper chart
in the electronic chart it can begin any time after admission and revised throughout the hospitalization
scheduled medications
are to be given on a regularly scheduled basis
unscheduled medications
medication that are to be given on call at the appropriate time
continuous infusions
IV fluids that are running consistently unless stopped for a blood transfusion or to give an IV medication that in not compatible with the IV fluid running
prn
as needed
STAT medication
given immediately and only once
single-order medicaiton
given once at a separate time, not necessarily immediately
injections
if you administer you must chart the site of administration
Kardex
is a special paper form or folding card that briefly summarizes a patients status and plan of care
Integrated Plan of Care (IPOC)
combined charting and care plan form
Occurrence report or incident report
A formal record of an unusual occurrence or accident
OASIS
Outcome and Assessment Information set
Used in home health documentation
Minimum data set (MDS)
Used in Long term care documentation
for resident assessment and care screening within 14 days of admission
Must be updated every 3 months with any significant change in client condition
handoff report
to alert the next caregiver about the clients status or recent changes in the clients condition and to discuss planned activities, tests, procedures, or concerns that require f/u
bedside report
walking rounds
allows you to observe important aspects of care
face to face oral report
may involve only the outgoing and oncoming nurse r may include the entire oncoming shift
audio-recorded report
a convenient way to transmit info
the outgoing nurse audio-records a report on her patients
PACE
standardized report form Patient/Problem Assessment/Action Continuing/Changes Evaluation
SBAR
Situation
Background
Assessment
Recommendation
Verbal orders
spoken directions for patient care given to you in person, usually during an emergency
Communication
a dynamic, reciprocal process of sending and receiving messages
Intrapersonal communication
is conscious internal dialogue, sometimes known as self-talk
Interpersonal communicaiton
occurs between two or more people
Group communication
interaction occurring among more than two people
Public speaking
unique form of group communication
generally addressing a large group
Communication process
the act of sending, receiving, interpreting, and reacting to a message
sender
begins the conversation to deliver a message to another person
encoding
the process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message
message
the verbal and/or nonverbal info the sender communicates
channel
the medium used to send the message