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