Documentation
Another name for Patient's chart
Type of charting: based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented.
What is Exception charting?
What does a.c. Mean?
What is before meals?
What does chondral mean?
what is Of or relating to cartilage?
what does pan mean?
what is all?
A way to chart: Organized according to the person charting. There are separate forms that indicate nursing, physicians, and other professionals. Assessments usually follow a body systems format.
What is Source Oriented or Narrative Charting?
type of charting: goal for every future patient. Also known as the EHR. Documentation done as interventions are performed using bedside computers.
What is Computer-assisted charting?
What does bid mean?
what is twice per day?
What does cysto mean?
what is urinary bladder, cyst, or sac of fluid?
what does para mean?
what is near, beside, abnormal, apart from, along side of?
Type of charting: Includes problem identification, interventions, and evaluation. Follows the nursing process and uses nursing diagnoses. Does not require additional narrative documentation.
Type of charting: a method of organizing patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost.
What is case management charting?
what does gtt mean?
what is drops?
What does Adeno mean?
what is a gland?
was does scler mean?
what is hardening/whites of eyes
Type of charting: Focuses on patient status. There are five basic parts : database, problem list, plan, progress, notes, and discharge summary.
what is POMR or Problem Oriented Medical Record Charting.
What does HTN mean?
What is hypertension?
What does carcino mean?
what is cancer/cancerous?
what does penia mean?
what is deficiency?
Focus charting.
What does ASA mean?
What is aspirin?
What does erythro mean?
what is red?
what does algia mean?
what is pain?