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23 Cards in this Set
- Front
- Back
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What is a health history? |
Include physical, psychological, cultural, spiritual, and psychological data. It’s the main source of information about the patients health status and guides the physical exam that follows |
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Name the two types of charting systems |
Source oriented narrative method and problem oriented method |
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List the things you would not do:say in a health history |
Do not ask judgemental or threatening questions, ask persistent questions or probe, or offer advice or false reassurance |
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List you things you DO say during a health history |
Do use general leads, ask open-ended questions, restate information, encourage patient |
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What does S stand for? And 2 examples |
Subjective data (chief complaint or other impressions) |
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What does O stand for? |
Objective data (observed signs and symptoms or laboratory test values) |
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What does A stand for? |
Assessment data (conclusions based, collect information on subjective and objective data and this dynamic ongoing process changes as more information becomes known |
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What does P stand for? |
Plan (strategy for relieving the patients problem, immediate, short term and long term measures |
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Describe charting/documentation |
The process of preparing a complete record of a patient’s care |
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Who is health care evaluated by? |
Reviewers, insurance companies, lawyers or judges |
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Give 3 examples of what is in a medical record |
Identification data, medical history, evidence of informed consent, and final diagnosis |
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What does POMR stand for? |
Problem oriented medical record |
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What is computerized charting and list 2 benefits |
A popular form of charting for completing medical records from admission to discharge. Benefits include: promoted standardization, aids team communication |
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What are the 6 phases of the nursing process? |
Assessment, nursing diagnosis, outcome identification, planning xare, implementation, evaluation |
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What does PIE stand for? |
Problem intervention evaluation |
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What does AIR stand for? |
Assessment intervention response |
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What can computerized documentation assist you with? |
Nurse management reports, staff scheduling, and staff projections |
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List a negative outcome of computerized charting? |
The potential for unauthorized personnel to access confidential medical records |
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What are the 7 fundamental rules when charting? |
Document care completely, concisely, and accurately, record observations objectively, document information promptly, write legibly, use approved abbreviations, use proper techniques to correct written errors, sign all documents as required |
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Three different types of orders |
Written or electronic orders, verbal orders, preprinted orders |
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3 main skills needed in the workplace |
Fundamental skills, personal management skills, teamwork skills |
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What skills are essential for employment? |
Listening, reading, speaking, interpersonal, writing |
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What does PAIBOC Stand for? |
Purposes, audience, information, benefits, objections, context |
