Patient Encounter/med Records

Question 0

What is the social space used for?

Answer 0

Introductions
Establishing patient rapport
Identifying patient

Question 1

Social space is how many feet from the patient?

Answer 1

4-12

Question 2

What is the acceptable distance for personal space?

Answer 2

18inches- 4 feet

Question 3

What is personal space used for?

Answer 3

Interview of patient

Question 4

How far are you from the patient while in the intimate space?

Answer 4

0-18 inches

Question 5

What is the intimate space used for?

Answer 5

Physical exams/procedures

Question 6

What does PHI stand for?

Answer 6

Protected health information

Question 7

Who controls access to PHI

Answer 7

Patients

Question 8

What does CDC stand for?

Answer 8

Center for Disease Control

Question 9

What does the CDC of encourage all clinicians?

Answer 9

To wear protective gear if they will come in contact with bodily fluids of patients

Question 10

Why are the Speak Up steps so important?

Answer 10

They help prevent errors in your care

Question 11

One word the the S in speak up is associated with

Answer 11

Questions..

Question 12

What does the P in speak up stand for?

Answer 12

Pay attention

Question 13

Speak Up with an E

Answer 13

Educate yourself

Question 14

The A means what in care safety

Answer 14

Ask an advocate

Question 15

The K represents what?

Answer 15

Know what your taking

Question 16

The U means what?

Answer 16

Use a researched facility

Question 17

The P means…?

Answer 17

Participate in decisions

Question 18

What are the sections of electronic medical records

Answer 18

Admitting information
DRG (diagnostic related group)
History and assessment
Laboratory and imaging 
Nurses notes 
Nursing admission assessment/patient data
Graphic sheet 
Respiratory therapy notes 
Admission note 
Progress notes 
Status(resuscitate / intubate or not)

Question 19

What will you find under the admitting information section?

Answer 19

Employment
Insurance
Admitting diagnosis

Question 20

What is found under the DRG section?

Answer 20

500 different diagnosis

Question 21

What can be found under the section History and Assessment?

Answer 21

CC(chief complaint)
All past illness and hospitalizations
Social history
Physical assessment

Question 22

The laboratory and imaging section contains what info?

Answer 22

Lab diagnostic procedures and results