Patient Encounter/med Records Flashcards
What is the social space used for?
Introductions
Establishing patient rapport
Identifying patient
Social space is how many feet from the patient?
4-12
What is the acceptable distance for personal space?
18inches- 4 feet
What is personal space used for?
Interview of patient
How far are you from the patient while in the intimate space?
0-18 inches
What is the intimate space used for?
Physical exams/procedures
What does PHI stand for?
Protected health information
Who controls access to PHI
Patients
What does CDC stand for?
Center for Disease Control
What does the CDC of encourage all clinicians?
To wear protective gear if they will come in contact with bodily fluids of patients
Why are the Speak Up steps so important?
They help prevent errors in your care
One word the the S in speak up is associated with
Questions..
What does the P in speak up stand for?
Pay attention
Speak Up with an E
Educate yourself
The A means what in care safety
Ask an advocate
The K represents what?
Know what your taking
The U means what?
Use a researched facility
The P means…?
Participate in decisions
What are the sections of electronic medical records
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)
What will you find under the admitting information section?
Employment
Insurance
Admitting diagnosis
What is found under the DRG section?
500 different diagnosis
What can be found under the section History and Assessment?
CC(chief complaint)
All past illness and hospitalizations
Social history
Physical assessment
The laboratory and imaging section contains what info?
Lab diagnostic procedures and results
