Vital Signs
The normal range for this vital sign is **60-100** beats for minute.
What is heart rate?
What is the definition of a **Chief Complaint**
What is the patient's main reason for seeking care, stated in their own words?
This acronym refers to the legal principle that if it isn't written it didn't happen.
What is "IFWIDH" or "If it wasn't documented, it didn't happen?"
What is the first phase of the clinical reasoning process?
What is data collection or assessment?
The vital sign should be measured for **one full minute** in infants for accuracy.
What is the respiratory rate?
This element should **not** be included inside the chief complaint.
What are diagnostic interpretations or clinician assumptions?
This documentation style is broken into** Subjective, Objective, Assessment, Plan**.
What is SOAP note?
Clinicians make this type of judgement that involves evaluating patient information to prioritize issues.
What is clinical judgement or triage?
A reading of **140/90 mmHg or higher** is classified as this condition.
What is hypertension?
A well written CC should be **how detailed?**
What is "a few words toa short phrase?"
Time sensitive events such as medication administration must be recorded using this standard practice.
What is real time or immediate documentation?
This cognitive action helps providers consider alternative explanation's to avoid diagnostic errors.
What is differential diagnosis formulation?
This temperature route is consider the most accurate for core body temperature?
What is rectal temperature?
if a patient says, "I cant catch my breath", the CC should be documented as this.
What is "shortness of breath"
When documenting, providers must avoid using this type of undefined terminology, such as "appears fine" or "seems normal".
What is vague or subjective language?
identifying which patient problem needs to be addressed **first** uses this critical thinking framework.
What is prioritization or the ABCs?
(Airway, Breathing, Circulation)
**SpO2 below 90%** on room air indicates this clinical condition.
What is hypoxemia?
This tool or method helps ensure the CC is accurately captured from non-verbal or distressed patients.
What is the use of clarifying questions or alternative communication methods?
(i.e gestures, boards, translation apps)
This is the legal term for altering a chart after the fact, which is prohibited unless properly amended.
What is falsification of medical records?
This term refers to the mental process of questioning assumptions to prevent biased decision making?
What is metacognition or reflective thinking?