vital signs
What's the Average Respiration Rate for an Adult.
12-20
Pt comes in w/ myocardial infraction
Chest pain
What is the Chief Complaint?
This is the first step in taking a patients history, where you gather information on the reason for the visit.
This term refers to the process of writing down information about a patient’s care, treatment, and progress.
Charting or Documentation
This process involves evaluating patient symptoms/ history to determine possible diagnoses.
Clinical Reasoning.
What's the average oral temperature for and adult?
Pt comes in wheezing
Respiratory complaint
What is Social History?
This section assesses lifestyle factors, such as alcohol use, tobacco smoking, occupation, sexual activity, and living conditions.
This federal law protects patient health information.
HIPAA
Avoiding assumptions about a patients condition and relying evidence demonstrates this critical thinking skill.
Objectivity
What is Respiratory Rate?
Number of breaths a person takes per minute.
Pt comes in with appendicitis
Abdominal pain
What is Family History?
This part of the history-taking identifies genetic, conditions or diseases that might run in the family and may affect the patient's health.
If error made in documentation, what's the correct way to fix it.
Draw single line through error and write correction with initial and date.
Evaluating the credibility of a new study before applying it to patient care.
Evaluation
What is Tachycardia?
Pulse rate over 100 bpm
Pt comes in w/ stroke
Head & Neuro complaint
What are Immunizations?
This identifies which vaccines the patient has received, as well as when they were last administered.
Leaving out critical patient information in documentation could be considered what violation?
Negligence or Malpractice
Identifying inconsistence in patient data.
Critical analysis.
What's measures SpO2?
Pulse Oximeter
Pt comes in with gastroenteritis
Abdominal pain
What is the Review of Systems?
A systematic approach to asking the patient about symptoms across various organ systems, such as cardiovascular, respiratory, and neurological.
This type of documentation ensures that even handwritten or electronic notes are legible complete and signed.
Compliance with documentation standards
Recognizing trend across multiple patients in a clinical setting to improve care is called...
Pattern Recognition