Test 5 Study Guide Flashcards
Reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care
Medication reconciliation
Key uses for medical record
- Describe information pertinent to the patient.
- Provide for continuity in information about patient treatment.
- Act as a method for evaluating quality of care.
- Serve as a basis for reimbursement.
- Function as a tool for evaluating resource allocation.
- Serve as a legal document.
Elements of a patient medical record (14)
- Progress Notes
- Physician Orders
- Discharge Summary
- Flow/Graph Sheets
- Lab reports
- Medication Administration
- Digital images/recordings
- Radiology Reports
- Monitoring Strips
- Admissions Sheet
- History/Physical Examination
- Consultation Sheet
- Consent Forms
- Surgical Records
Five characteristics that are consistent within HROs
(1) Their preoccupation with failure.
* (2) Reluctance to simplify interpretations.
* (3) Sensitivity to operations.
* (4) Commitment to resilience.
* (5) Deference to expertise.
National Patient Safety Goals (6)
- Identify patients correctly
- Improve staff communication
- Use medications safely
- Use alarms safely
- Prevent infections
- Identify patient safety risks
Patient confidentiality is protected by ____
Heath Insurance Portability and
Accountability Act (HIPPA)
Intended to ensure the privacy and protection of personal records and
data in an environment of electronic medical records and third-party insurance
payers.
HIPPA
provides a uniform set of guidelines that apply to all providers and
organizations
HIPPA
designed to intervene during the critical prearrest
period when patients often demonstrate clinical warning signs of pending
demise.
Rapid Response Team
Goals of rapid response team
Preventing intensive care unit transfer
* Preventing cardiac arrest
* Preventing death
should be conducted immediately before starting the procedure.
Time out
- During the time-out, the team members agree, at a minimum on:
The correct patient identity
* Correct site
* The procedure to be done.
a structured method
used to identify underlying problem issues or analyze
serious adverse events.
Root Cause Analysis (RCA)
The process was initially developed to help analyze industrial accidents but now is widely used in health
care to analyze errors.
Root Cause Analysis (RCA)
the most common complication of
hospital care
Healthcare-associated infections (HAIs)
How many deaths associated with HAI’s in the U.S. each year.
75,000
These Five infections together account for the majority of all HAI’s:
- Surgical site infections (SSI’s)
- Cather-associated urinary tract infections (CAUTI’s)
- Central line bloodstream infections (CRBSI’s)
- Pneumonia
- Gastrointestinal infections (Clostridium difficile associated disease (CDI))
On average, ___% of adults aged 65 and over have at least one chronic condition,
and ___% have at least two.
80% and 50%
Defined as the average number of years an individual is expected to live, either from birth
or the number of years remaining at any given age.
Life Expectancy
a multidimensional,
interdisciplinary diagnostic process to determine the medical, psychological,
and functional capabilities of a frail elderly person in order to develop a
coordinated and integrated treatment plan.
Comprehensive Geriatric
Assessment (CGA)
The elderly have a reduction in _____ gas exchange surface area
Alveolar
In the elderly, the alveoli ____, and Pores of Kohn become larger.
Dilate
Likely due to changes in elasticity in the parenchyma.
