Recording & Reporting (Ma'am Tessie Reyta) Flashcards
Documentation
Recording
Relaying the information
Reporting
Collection of all prominent facts in a person’s treatment & medical history
Medical or Health Record
Medical Health Record serve as
The basis for planning care
Providing documentation
Confidential
Communicating between medical provides and other work
should reflect observed facts
all account of the person’s condition and care in writing and signed by the person giving care
FACC
Facts, Accuracy, Completeness, and Currentness
ABC
Accurate, Brief, Completely Objective
taking information from a medical provider’s order and transferring them to the MAR
Transcribing
____ marks are never used
“DITTO”
Do not initial that medication was given ______ it is administered
before
Your _____ & _____ must be in appropriate space on each MAR
initials & signature
Never ___ or use any kind of liquid eraser
erase
Record onto MAR immediately ___ you see that the medication was swallowed
AFTER
If a medication is not taken as ordered for any reason, follow the _________
agency protocol
If the person resists
Make attempts, assist person
generally used in an emergency basis. Drug should be administered as soon as possivle
STAT order
“One time” / at a certain time
SINGLE order
medication to be given for a specific number of dose, discontinued at a latter date
STANDING order
written and signed by the physician before the nurse can continue to administer medication
RENEWAL order
Needed, allows the nurse to judge when a medication should be administered based on a patient’s need
PRN order
Telephone orders, “read back” to ensure accuracy
Verbal order
What are the seven parts of a drug order
Date and time of order
Patient name
Drug name
Dosage
Route of administration
Frequency/time and any special instruction
Signature of nurse of a personal unity with the order
IM
Intramuscular
IV
Intravenous
IVPB
Intravenous piggyback
