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48 Cards in this Set
- Front
- Back
medical records
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written collection of info about a person's health, care provided by doc.s/nurses and clients progress
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Chart
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binder/folder; promotes collection, storage & safe keeping of person's MR's
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Different kinds of charts:
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fact, teaching, labs, directives, Doc's orders and admission
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Quality Assurance
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internal process for self-improvement to ensure the level of care reflects or exceeds est standards
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Who does accreditation
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JCAHO
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Why do charts?
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quality assurance, accreditation, reimbursement, education, & legal evidence.
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Source-oriented
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organized according to the source of documentation
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Problem-oriented
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by the client's health problem
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Charting Methods are:
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Narrative, SOAP, FOCUS, DAR, Pie, exception & computerized
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Narrative Charting
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entry like a journal, source oriented
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SOAP Charting
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(problem oriented)
S-subjective data O-objective data A-analysis of data P-plan for care |
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FOCUS Charting
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modified soap charting
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Pie Charting
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record under heading:
problem intervention and evaluation |
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Charting by Exception
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chart only abnormal assessment findings
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Computerized Charting
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client info electronically
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Traditional Time
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two 12 hour revolutions of the clock
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Military Time
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based on a 24 hour clock
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Written forms of Communication
(4) |
Nursing care plan, nursing Kardex, chechlists and flow sheets
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Interpersonal Communications
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change of shift report, client care assessment, client rounds and telephone
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Nursing Care plan
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list of problems, goals and nursing orders for client care
(can be revised) |
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Nursing Kardex
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quick reference about client & their care
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Checklists
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nurse shows w/a check mark or initials the performance of routine care
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Flow sheets
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W/sections for recording frequently repeated assessment data
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Change of shift Report
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communication between nurse going off and nurse going on duty
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Client Care Assignment
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at the beginning of every shift, what the job will be
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Team Conference
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exchange of info in a group
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Client Rounds
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visit to clients as an individual or as a group
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telephone
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exchange of info
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Admission
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entering a health care agency for nursing care & medical or surgical treatment
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Steps in admission:
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physicians authorization, collection of billing info and completion of admission database
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Inpatient
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stay more then 24 hours
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Outpatient
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stay less then 24 hours
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Medical authorization
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determines whether a patient should be admitted
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Admission Department
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gain info about the patient's med. history, insurance ect.
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Nursing Admission activities
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-prepare the room
-welcome the client -orient the client -safe guard valuables -help the client undress -compiling the nursing database |
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Initial plan for care
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ID problems and includes projected needs
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Medical admission responsibilities
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doc gives order for care
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Common responses to admission by clients
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loneliness, anxiety, decreased privacy, loss of identity ect
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Discharge
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termination of care from the health care agency
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Discharge planning
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improves client outcome
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Transfer
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discharging a client from unit or agency and admitting him/her to another w/o going home interim
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Could go to these places in transfer:
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step-down units, progressive care units &traditional care units
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What to do in Activities Transfers:
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-inform patient and family
-write a transfer summary |
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Extended Care Facilities
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health care agency that provides long-term care
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Skilled Nursing Facility
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24 hour nursing care, under direction of an RN
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Intermediate Care
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care for mental and physical conditions
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Basic care
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agency that provides extended custodial care
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Continuity of Care
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uninterrupted client care despite the change in caregivers
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