Unit 2 ~ Documentation

Question 1

What is documentation?

Answer 1

Essential part of nursing. Occurs in health care record.

Question 2

What is confidentiality?

Answer 2

Legal and ethical obligations. Protection of information.

Question 3

What is the purpose of the chart?

Answer 3

Communication among disciplines, legal document, education, research, and auditing.

Question 4

What is the electronic health record?

Answer 4

Over several periods of time, ready to access no, it’s efficient, and there’s some legal implications if system gets hacked.

Question 5

What type of record is a traditional chart and each discipline has its own section?

Answer 5

Source orientated record.

Question 6

What is a problem-orientated record?

Answer 6

Based on patient’s problems. All disciplines document on the same notes.

Question 7

What is narrative charting?

Answer 7

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.

Question 8

What does SOAP stand for?

Answer 8

Subjective, objective, assessment, and plan. (subjective is symptoms from patient and objective is what we observe).

Question 9

What does SOAPIE stand for?

Answer 9

Subjective, objective, assessment, planning, intervention, and evaluation.

Question 10

What do we use to organize progress notes (hint: PIE).

Answer 10

P-problem
I- intervention
E- evaluation
Gives a narrower view of patient.

Question 11

What is focus charting?

Answer 11

Based on patients concerns and uses DAR (data, action, response).

Question 12

What is charting by exception (CBE).

Answer 12

Assume everything is fine unless there’s something going on. Document deviations from normal.

Question 13

What is case management?

Answer 13

It’s interdisciplinary. Pathway for specific disease. Critical pathways are care maps (can incorporate CBE).

Question 14

What is Kardex?

Answer 14

A temporary record, like a recipe card. Snapshot of what’s happening to the patient right now.

Question 15

What is a discharge summary?

Answer 15

It’s given to patient at the end of their stay. You start to fill it out when the patient is close to leaving.

Question 16

What are some guidelines for documentation?

Answer 16

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.

Question 17

What is reporting?

Answer 17

Communication to others for change of shift/transfer of patients.

Question 18

What are the 3 types of medical terminology?

Answer 18

1. Latin/greek word parts
2. Eponyms- based on persons name (e.g. someone who discovered or wrote about the disease)
3. modern English words

Question 19

What is a word root?

Answer 19

It is the foundation of most terms. Gives meaning to body structure/organ/system. E.g. cardi, neuro.

Question 20

What ends a medical term and is included in all medical terms? It also adds info to word root.

Answer 20

Suffix e.g. -pathy (disease)

Question 21

What is a prefix?

Answer 21

Begins a medical term and isn’t included in every term. E.g. hypo-.

Question 22

What does combing vowel mean?

Answer 22

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”.

Question 23

What does combing form mean?

Answer 23

The word root is written with its combing vowel. E.g. gast/o.

Question 24

What does arthr, carcin, cardi, cephal, electr, gastr, hepat, my, oste, and rhin stand for? (all are word roots)

Answer 24

Joint, cancer, heart, head, electricity, stomach, liver, muscle, bone, and nose.

Question 25

What does a-, bi-, dys-, inter-, post-, and sub- stand for?

Answer 25

Without, two, abnormal/difficult/painful, between, after, and under.

Question 26

What does -ectomy, -gram, -itis, -logy, -megaly, and -pathy stand for?

Answer 26

Surgical removal, a record, inflammation, study of, enlarged, and disease.

Question 27

What does cardi and cerebr stand for?

Answer 27

Heart and brain.

Question 28

What does col, colon and crani stand for?

Answer 28

Colon and cranium/skull.

Question 29

What does dermat and gastro stand for?

Answer 29

skin and stomach.

Question 30

What does nephr/ren and oste stand for?

Answer 30

Kidney and bone.

Question 31

What does pulmon, thrombo, thorac, abdomen, and viscera stand for?

Answer 31

Lung, clot, chest, belly, and internal organs.

Question 32

What does a- and dys- stand for?

Answer 32

Without/not and abnormal.

Question 33

What does inter- and intra- stand for?

Answer 33

In between and within.

Question 34

What does peri- and poly- stand for?

Answer 34

Around and many/much.

Question 35

What does post-, sub-, and supra- stand for?

Answer 35

After/behind, below, and above.

Question 36

What does brady-, eu-, hyper-, and tachy-?

Answer 36

Slow, good/normal, excessive, and rapid/fast.

Question 37

What does -ac/-al/-ary/-ic/-ous and -algai/-dynia stand for?

Answer 37

Pertaining to and pain.

Question 38

What does -ectomy and -ism/-ia stand for?

Answer 38

Surgical removal and state/condition.

Question 39

What does -itis, -logy, and -iem stand for?

Answer 39

Inflammation, study of, and tissue/structure.

Question 40

What does -oma, -tomy, and -megaly stand for?

Answer 40

Tumour, incision, and enlarged.

Question 41

What does -plasia, -plegia, and -rrhea stand for?

Answer 41

Formation of growth, paralysis, and discharge.

Question 42

What does p.o. stand for?

Answer 42

By mouth

Question 43

What does prn and tid stand for?

Answer 43

As necessary and three times daily.

Question 44

What does IM stand for?

Answer 44

Intermuscularlarly.

Question 45

Do we use the trade name of medicine products or the generic name?

Answer 45

Generic

Question 46

What does q4h stand for?

Answer 46

Every 4 hours.