OTHER SOURCES OF DATA Flashcards
healthcare provider will write all the problems noted ; date when observed and resolved ; track problems
problem list
see the patient’s database, chief complaints, and other pertinent information that the examiner can write upon admission
emergency room admission sheet
its important to secure this so patient cant deny any hospitalization
consent for admission, healthcare and diagnostic procedures
the doctor can write the patient’s complain, history of present illness, and past medical history
department of pediatric general data
healthcare provider can write all the progress that the patient have achieved during his or her stay in the hospital ; basis for payment of insurance
progress notes
if the patient is for 15 or 30 mns monitoring we can write that in the
vital signs sheet for patient under close observation
nurse must be aware of the patient’s fluid intake through oral or parenteral
intake and output
you can see here the doctor’s order so that nurse can follow through and carry out those orders
physician’s notes
graph the vital signs that you are able to gather ; trace if vital signs are fluctuating or not
vital signs clinical chart
nurses must affix their initial on a given medication on a specific time
medication and treatment record
nurses must write the first initial IV bottle until the IV was terminated or stopped
intravenous fluid sheet
the healthcare provider must write the pertinent information data ; accomplished before patient will be billed out
discharge summary
nurse must write all those pertinent information that gathered in terms of problems, assessment, management and response of the patient
nurse’s notes
what is the usual formate of nurse’s notes
FDAR
