Medical Chart Review - Class 1 Flashcards

1
Q

subjective interview could provide

A

basic info required for beginning to asses a pt’s condition

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2
Q

what do tx of hospital or nursing home in-pts provide

A

slightly different interview or info gathering format

review of the medical chart

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3
Q

review of the medical chart

A

provides important info

may be only source of info if the pt is unconscious, a poor historian or if there is a language barrier

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4
Q

what does reviewing the chart assist with

A

developing a safe and effective tx plan

important to be aware of this vital info before beginning tx

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5
Q

important info to look for in the medical chart

A

pt’s age

social history

admitting dx and any concurrent dx

hospital course

physicians orders

other medical problems

meds

lab values

vital signs

nursing assessment

discharge plans

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6
Q

social history

A

where the pt lives

what type of home or apartment they live in

leisure activities

use of tobacco

alc

elicit drugs

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7
Q

hospital course

A

will gather any info to reconstruct the pt’s hospital stay

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8
Q

hospital course should include

A

date of admission

any events or procedures since admission

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9
Q

where is info about procedures/events found

A

physicians report

daily notes

documentation from other members of the health care team

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10
Q

physicians orders

A

look for orders for PT

pre and post op orders

contraindications for tx

weight bearing limits

cardiac or pulmonary precautions

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11
Q

other medical problems

A

DM

heart dx

PVD

respiratory involvement

syncope

seizures

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12
Q

meds

A

what meds

when do they take them

any side effects

is the pt receiving O2 or IV fluids

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13
Q

lab values could include

A

blood gases

WBC count

hematocrit/hemoglobin levels

ECG results

pulmonary fxn tests

MRI

Xrays

etc.

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14
Q

lab results may

A

affect daily tx

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15
Q

lab results need to be checked

A

prior to every PT tx

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16
Q

vital signs

A

BP

HR

RR

17
Q

what do we want to know w/ vital signs

A

if their BP is stable

18
Q

nursing assessment includes

A

medical status

pain

physical status

pt orientation

19
Q

medical status

A

what is the pt’s current status?

20
Q

pain

A

what is the nursing assessment of pt’s pain level and pain tolerance

21
Q

physical status

A

his the pt been out of bed at all

have they been standing or walking

how much assistance is required

22
Q

pt orientation

A

are they oriented to time, place and person

23
Q

what does a PT does with pt orientation

A

also evaluate it and compare to nurses assessment

24
Q

d/c plans

A

are they any know d/c plans

is there a planned d/c date