Health Assessment, ISOBAR, Documentation, PQRST Flashcards
What does Q stand for?
Quality and quantity.
How does it look, feel, sound or smell like?
How much of it is there?
In symptom assessment (PQRST), what does P stand for?
Provoking and palliative.
What causes it?
What makes it better/worse?
What does R stand for?
Region and radiation.
Where is it?
Does it spread to other areas?
What does S stand for?
Severity and scale.
Does it interfere with activities?
Can you rate it on a scale from 0-10?
What does T stand for?
Timing and type of onset.
When did it begin?
How often does it occur?
What are the components of a health history?
- Past health history
- Family health history
- Environmental & lifestyle
- Psychosocial history and developmental level
What sources of data can you use for health history?
Patient
Family and significant others
Healthcare team members
Healthcare records
What are the main principles for record keeping (documentation)?
Record date and time
Legible entries
Permanent ink black/blue
Use recognized & approved terminology and abbreviations
Accuracy of patient identification and events
What are the ethical principles fir record keeping?
Confidentiality and privacy
Details related to consent to treatment
Use of patient records in research
What are the legal considerations of documentation?
Proof of nursing care provided
Evidence
Protection
How do you correct a error on documentation?
Correct errors promptly.
Pull a line through, write error at the top and your initials
True/False
Do not record all relevant information.
False.
Record ALL relevant information.
What are the documentation guidelines?
Do not leave blank spaces.
Record all entries legibly and in blue/black ink.
Chart only for yourself.
Only document changes and interventions.
Use recognized abbreviations.
What do you begin each entry with?
The date and the time.
What do you end each entry with?
Signature and designation = M. Buhlmann (Buhlmann) Student RN
