Unit 2 ~ Documentation Flashcards
What is documentation?
Essential part of nursing. Occurs in health care record.
What is confidentiality?
Legal and ethical obligations. Protection of information.
What is the purpose of the chart?
Communication among disciplines, legal document, education, research, and auditing.
What is the electronic health record?
Over several periods of time, ready to access no, it’s efficient, and there’s some legal implications if system gets hacked.
What type of record is a traditional chart and each discipline has its own section?
Source orientated record.
What is a problem-orientated record?
Based on patient’s problems. All disciplines document on the same notes.
What is narrative charting?
It takes the longest and gives the most detail. We use this one in lab. Use military hours and sign with name and school. Tells a story.
What does SOAP stand for?
Subjective, objective, assessment, and plan. (subjective is symptoms from patient and objective is what we observe).
What does SOAPIE stand for?
Subjective, objective, assessment, planning, intervention, and evaluation.
What do we use to organize progress notes (hint: PIE).
P-problem
I- intervention
E- evaluation
Gives a narrower view of patient.
What is focus charting?
Based on patients concerns and uses DAR (data, action, response).
What is charting by exception (CBE).
Assume everything is fine unless there’s something going on. Document deviations from normal.
What is case management?
It’s interdisciplinary. Pathway for specific disease. Critical pathways are care maps (can incorporate CBE).
What is Kardex?
A temporary record, like a recipe card. Snapshot of what’s happening to the patient right now.
What is a discharge summary?
It’s given to patient at the end of their stay. You start to fill it out when the patient is close to leaving.
What are some guidelines for documentation?
Be timely, use logical order, military time, write in black/blue ink, sign all entries: name, school, NS, be accurate, use accepted abbreviations/symbols, and be thorough.
What is reporting?
Communication to others for change of shift/transfer of patients.
What are the 3 types of medical terminology?
- Latin/greek word parts
- Eponyms- based on persons name (e.g. someone who discovered or wrote about the disease)
- modern English words
What is a word root?
It is the foundation of most terms. Gives meaning to body structure/organ/system. E.g. cardi, neuro.
What ends a medical term and is included in all medical terms? It also adds info to word root.
Suffix e.g. -pathy (disease)
What is a prefix?
Begins a medical term and isn’t included in every term. E.g. hypo-.
What does combing vowel mean?
Placed between 2 word roots or a word root+suffix (if the suffix begins with a vowel then its not a combing vowel, opposite for consonants). It’s usually an “o”.
What does combing form mean?
The word root is written with its combing vowel. E.g. gast/o.
What does arthr, carcin, cardi, cephal, electr, gastr, hepat, my, oste, and rhin stand for? (all are word roots)
Joint, cancer, heart, head, electricity, stomach, liver, muscle, bone, and nose.
What does a-, bi-, dys-, inter-, post-, and sub- stand for?
Without, two, abnormal/difficult/painful, between, after, and under.
What does -ectomy, -gram, -itis, -logy, -megaly, and -pathy stand for?
Surgical removal, a record, inflammation, study of, enlarged, and disease.
What does cardi and cerebr stand for?
Heart and brain.
What does col, colon and crani stand for?
Colon and cranium/skull.
What does dermat and gastro stand for?
skin and stomach.
What does nephr/ren and oste stand for?
Kidney and bone.
What does pulmon, thrombo, thorac, abdomen, and viscera stand for?
Lung, clot, chest, belly, and internal organs.
What does a- and dys- stand for?
Without/not and abnormal.
What does inter- and intra- stand for?
In between and within.
What does peri- and poly- stand for?
Around and many/much.
What does post-, sub-, and supra- stand for?
After/behind, below, and above.
What does brady-, eu-, hyper-, and tachy-?
Slow, good/normal, excessive, and rapid/fast.
What does -ac/-al/-ary/-ic/-ous and -algai/-dynia stand for?
Pertaining to and pain.
What does -ectomy and -ism/-ia stand for?
Surgical removal and state/condition.
What does -itis, -logy, and -iem stand for?
Inflammation, study of, and tissue/structure.
What does -oma, -tomy, and -megaly stand for?
Tumour, incision, and enlarged.
What does -plasia, -plegia, and -rrhea stand for?
Formation of growth, paralysis, and discharge.
What does p.o. stand for?
By mouth
What does prn and tid stand for?
As necessary and three times daily.
What does IM stand for?
Intermuscularlarly.
Do we use the trade name of medicine products or the generic name?
Generic
What does q4h stand for?
Every 4 hours.
