Documenting
Reporting
Vital Signs
Vital Signs 2
Communication
100
The act of recording patient status and care in written or electronic form, or in a combination of the two forms.
What is Documentation?
100
This type of system organizes the patient's record around the patient's problems.
What are problem-oriented records?
100
Suggests assessment of critical physiological functions?
What are Vital Signs?
100
This is the total quantity of blood pumped per minute.
What is cardiac output?
100
A dynamic, reciprocal process of sending and receiving messages.
What is communication?
200
Oral communication about a patient's status.
What is reporting?
200
A system of charting in which only significant findings or exceptions to standards and norms of care are charted.
What is charting by exception?
200
These measurements represent core body temperatures.
What are rectal and tympanic membrane temperatures?
200
____________refers to the paleness of skin in one area when compared to another part of the body.
What is pallor?
200
The use of spoken and written words to send a message.
What is verbal communication?
300
This permanently documents, care in chronological order that is provided by all healthcare providers, the patient's responses to interventions and treatments, important facts about a client's health history, including past and present illnesses, examinations, tests, treatments, and outcomes.
What is a health record?
300
S.O.A.P
What is subjective, objective, assessment, and plan?
300
The process of temperature regulation is this.
What is thermoregulation?
300
________________ is a bluish or grayish discoloration of the skin due to deficient oxygen in the blood.
What is cyanosis?
300
The implied or emotional meaning of a word.
What is connotation?
400
The overall process by which all patient records are created, stored, and retrieved in an organization.
What is a health records system?
400
This is the last entry made in the patient's chart.
What is a discharge summary?
400
A person with a fever is said to be...
What is febrile?
400
This is the number of times a person breathes within a full minute.
What is respiratory rate?
400
Body language.
What is nonverbal communication?
500
In this type of system, members of each discipline record their findings in a separately labeled section of the chart.
What is source-oriented records?
500
S.B.A.R
What is Situation, Background, Assessment, Recommendation?
500
This is the rhythmic expansion of an artery produced when a bolus of blood is forced into it by contraction of the heart.
What is pulse?
500
Labored breathing.
What is dyspnea?
500
This focuses on improving the health of the client, whether an individual or community.
What is therapeutic relationship?
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