fucking forms

Question 1

NAVMED 6550/8

Answer 1

Medical Administration Record. documents medications administered during a seven day period. medications ordered by a physician are transcribed on the mar. front portion for staff signatures. front also allows for documentation of scheduled medications to be given on a reg schedule. the back side has two sections, top portion is for the doc of one time (stat meds) and preoperative meds.

Question 2

NAVMED 6550/12

Answer 2

patient profile. provide a ready reference of care for each patient. pertinent patient info: diagnosis, orders for medications, treatments, activity, diet, vital signs, bath, and intake and output

Question 3

SF 508

Answer 3

Dr’s orders. when the dr updates, discontinues, changes, or adds new orders, patient profile must be updated

Question 4

SF 509

Answer 4

Progress notes. describes chronologically the clinical course of inpatient. notes should reflect any change of condition and results of treatment.

Question 5

SF 510

Answer 5

Nursing notes, doc inpatient care. Date of entry (full date at head of each new form, entered each new day) Time of entry ( hour column) divided into am and pm. entries made with each new entry, military time. Observations are recorded on the main body ( patient condition, progress, care and treatment) most recent entry is found at the front of the nursing note section. all 510s are written and filed in chronological order. written objectively. use black pen. each entry is signed by the person who wrote the note, first name, last name, rank

Question 6

two types of formats for SF 510

Answer 6

block format and charting by exception

Question 7

block format

Answer 7

entries written in paragraph form, who, what, where

Question 8

charting by exception

Answer 8

used with ADL flow sheets, entries only identify unusual responses to treatment that deviate from the written standard

Question 9

how to chart on sf 510

Answer 9

chart: accurately, objectively, write legibly, do not criticise or complain, do not destroy or obliterate documentation, frequency dependent on pt condition, to add an entry write time and circle, write late entry and initial it

Question 10

SF 558

Answer 10

emergency care and treatment (alternate form from sf 600) used to doc all care given to pt in emergency room

Question 11

dd form 792

Answer 11

24 hour intake and output worksheet. front is intake, back is output. doc over 24 hour period, compared at the end of each shift and 24 hour period