Skills Lab #5 Flashcards
What is the technique of communication for health care team members to use that is not part of a patient’s permanent record?
a. ) Kardexes
b. ) SOAP notes
c. ) SBAR
d. ) Flowsheets
c.) SBAR
Describe SOAP notes
SOAP
Subjective data (what client says)
Objective data (what the nurse sees)
Assessment
Plan of action (nursing intervention)
Which of these terms stands for before meals?
a. ) a.c.
b. ) adm
c. ) p.c.
d. ) amt
Before meals
a.) a.c.
Which of these terms stands for administer?
a. ) a.c.
b. ) adm
c. ) p.c.
d. ) amt
Administer
b.) adm
Which of these terms stands for amount?
a. ) a.c.
b. ) adm
c. ) p.c.
d. ) amt
Amount
d.) amt
Which of these terms stands for after meals?
a. ) a.c.
b. ) adm
c. ) p.c.
d. ) amt
After meals
c.) p.c.
Which of these abbreviations means every night at bedtime?
a. ) qid
b. ) tid
c. ) qh
d. ) qhs
Every night at bedtime
d.) qhs
Which of these terms means out of bed?
a. ) OS
b. ) OD
c. ) OU
d. ) OOB
Out of bed = OOB
Right eye = OD
Left eye = OS
Both eyes = OU
Which of these terms means the left eye?
a. ) OS
b. ) OD
c. ) OU
d. ) OOB
Left eye = OS
Right eye = OD
Both eyes = OU
Out of bed = OOB
Which of these terms means the right eye?
a. ) OS
b. ) OD
c. ) OU
d. ) OOB
Right eye = OD
Left eye = OS
Both eyes = OU
Out of bed = OOB
Which of these terms means both eyes?
a. ) OS
b. ) OD
c. ) OU
d. ) OOB
Both eyes = OU
Right eye = OD
Left eye = OS
Out of bed = OOB
What do SOAP notes stand for?
Subjective - what the client says.
Objective - what the nurse sees and observes.
Assessment - conclusions from S&O nursing diagnoses.
Plan of action - nursing interventions, therapy orders, management of client problems.
What does SBARR stand for?
Effective communication of health care team members.
Situation, Background, Assessment, Recommendation, Read Back
Situation - concise statement of the problem.
Background - pertinent and brief information.
Assessment - analysis and consideration of options. What you found or think.
Recommendation - action requested or action recommended. What you want
