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69 Cards in this Set
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Definition: A mechanism for communication among healthcare professionals and it is a legal document of the patients health status
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Patient Chart
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Defintion: A system used to bring attention to key things within a patient chart
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A "flag system"
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How many medical charts are there per patient?
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One
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What is the first section of the patient medical chart?
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Admitting Data
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How many sections are in the Admitting Data?
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Four
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What are the four sections of the Admitting data?
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Biographical Data
Financial/Insurance Data Admissions-related Data Consent forms |
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Which section of the patient chart contains Biographical Data?
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Admitting Data
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Which section of the patient chart contains Financial/Insurance Data?
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Admitting Note
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Which section of the patient chart contains Admissions-related Data?
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Admitting Data
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*be sure to distinguish between admitting note (H&P) and admitting data
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Which section of the patient chart contains Consent Forms?
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Admitting Data
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Definition: Directives for patient treatment written either by a physician or by another health professional and countersigned by a physician
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Physician Orders
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What is another term for physician orders?
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Transcription
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Quantitative records of repetitive monitoring activities (arranged so patterns are easy to visualize)
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Graphic Charts
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Which section of the patient chart contains vital signs?
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Graphic Charts
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Which section of the patient chart contains blood glucose values?
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Graphical Charts
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Which section of the patient chart contains I&O data?
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Graphic Charts
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Which section of the patient chart contains IV fluid rates?
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Graphic Charts
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What type of information is displayed using graphic charts? (4)
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vital signs
I&O data blood glucose values IV fluid rates |
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Definition: A detailed summary of the patient's entire hospital course (from the nurses point of view)
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Nursing Notes
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Which section of the patient chart contains clinical signs and symptoms?
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Nursing Notes
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Which section of the patient chart contains nursing interventions?
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Nursing Notes
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Which section of the patient chart contains documentation of care?
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Nursing notes
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Which section of the patient chart contains nursing care plans?
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Nursing Notes
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Which section of the patient chart contains discharge care plans?
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Nursing notes
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Which section of the patient chart contains serum chemistries?
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Laboratory Values
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Which section of the patient chart contains lab test results?
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Laboratory Values
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Which section of the patient chart contains the results of diagnostic tests?
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Diagnostic Procedures/Consults/OR Procedures
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What is another name for History and Physical?
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Admitting note
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What is the largest section of the patient charge?
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History and Physical (Admitting note)
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Where does the physician usually write his or her initial findings and impressions?
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History and Physical (Admitting Note)
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How many componets are there in the admitting note?
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Six
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What are the six componets of the admitting note?
(History & Physical) |
Patient Identification
Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Assessment Plan |
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Which section of the patient chart contains patient identification?
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History and Physical (admitting note)
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Which section of the patient chart contains the chief complaint?
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History and Physical (admitting note)
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Which section of the patient chart contains history of present illness?
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History and Physical (admitting note)
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Which section of the patient chart contains past medical history?
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History and Physical (admitting note)
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Which section of the patient chart contains the assessment?
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History and Physical (admitting note)
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Which section of the patient chart contains the plan?
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History and Physical (Admitting note)
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Definition: The immediate problem that brought the patient to the hospital or the reason the patient was admitted.
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Chief Complaint
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CC
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Chief Complaint
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HPI
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History of Present Illness
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PMH
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Past Medical History
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FHx
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Family History
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SHx
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Social History
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Definition: Clear sequence of events that led the patient to seek medical attention.
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History of Present Illness
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Definition: Describes the patients more remote medical problems or illnesses that may or may not be related to the admitting note.
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Past Medical History
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What are the 5 componets of Past Medical History?
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Medication History
Family History Occupation Diet Social History |
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Which section of the patient chart contains medication history?
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Past Medical History
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Which section of the patient chart contains family history?
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Past Medical History
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Which section of the patient chart contains occupation?
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Past Medical History
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Which section of the patient chart contains diet?
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Past Medical History
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Which section of the patient chart contains social history?
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Past Medical History
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What is found in Social History?
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-marital status, sexual preference
-tobacco, alcohol use, illicit drugs -hobbies |
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What FOUR factors must be included in the Medication History?
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Drug name
Dose Regimen Duration |
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ROS
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Review of Systems
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PE
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Physical Exam
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MAR
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MEDICATION Administration Record
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Definition: A listing of all medications that the patient recieved while they were in the hospital.
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MEDICATION Administration Record
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POMR
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Patient-Oriented Medical Record
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What is the format of the Patient-Oriented Medical Record?
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1. Patient Data Base
2. The Problem List 3. Progress Notes |
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Which section of the Patient-Oriented Medical Record contains patient identification?
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Patient Data Base
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Which section of the Patient-Oriented Medical Record contains the chief complaint?
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Patient Data Base
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Which section of the Patient-Oriented Medical Record contains History of present illness?
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Patient Data Base
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Which section of the Patient-Oriented Medical Record contains past medical history?
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Patient Data Base
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Which section of the Patient-Oriented Medical Record contains Review of Systems/Physical Exam?
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Patient Data Base
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Definition: A running commentary on the patient's condition and treatments (including response to treatment from admission to discharge).
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Progress Notes
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Who does the patient medical CHART belong to?
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The hospital
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Who does the INFORMATION contained in a patient medical chart belong to?
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The patient
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Definition: A legal document of the health services provided to the patient during hospitalization.
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Patient medical chart
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