Drugs, Drugs, Drugs
These are filled in a healthcare setting.
What is a medication order?
All medications administered to residents are recorded on this.
What is Medication Administration Record (MAR)?
All documentation of resident care must be completed at this time.
What is when care is provided?
A kind of factual information based n what a person sees, hears, touches, or smells.
What is Objective Information?
These show how well the vital organs of the body such as the heart and lungs are working.
What are Vital Signs?
These are filled on an outpatient basis.
What is a prescription?
The most important reason medication documentation must be accurate
What is decisions about a resident’s care are based on these records?
Legally speaking, if something is not documented then what?
What is It Did Not Happen?
A kind of factual information based on something that the resident reported whether it is true or not.
What is Subjective Information?
Vital signs include these four readings.
What is temperature, pulse rate, respiratory rate, and blood pressure?
Orders for a medication to be administered immediately.
What is Stat Order?
These documents contain the same information regarding a resident’s medications.
What is a MAR and eMar?
This should be done if a MAR is missing any information.
What is notify supervisor prior to administering medication?
Vital signs are a type of this information.
What is Objective Information?
These measurements are the normal ranges for a particular person.
What are Baseline Vital Signs?
The amount of active ingredient in one unit
What is strength?
This should be done if a resident refuses a medication.
What is document the refusal?
Signs and symptoms of this include swelling of the lips, tongue and throat, and should be reported immediately.
What is Anaphylactic Reaction?
Something the resident reports is a type of this information.
What is Subjective Information?
A blood pressure of 127/79 is considered this.
What is Elevated?
This type of LTC facility document requires signatures or initials of more than one employee.
What is Controlled Substance Log?
This should be done immediately after the medication is administered
What is document?
This is defined as a blood pressure over 180 systolic or over 120 diastolic and must be reported immediately.
What is Hypertensive Emergency?
This type of information is most useful to the nurse and care team.
What is Facts?
These factors may affect vital signs. (Must answer 3 correctly) (Double Points for all 6)
What is Age, Medical Condition, Medications, Mental State, Room Temperature, and Noise?