Abbreviations
AMB
ambulatory
Information about past health conditions
Times for patient care is recorded as 2400, 1900
What is military time?
Patient
Drug
Dose
Route
Time
Assessment
Rational
Evaluation
Education
Documentation
What are the 10 medication rights?
These two methods of reporting has the disadvantage of accessibility since they do not provide a permanent record.
Face-to-face and telephone conversation.
H/A
Headache
Discarding copies of patient information in trash cans
Potential breach of confidentiality
Subjective & objective data, assessment, plan.
What is SOAP?
Communicates patient problems or diagnosis, goals, outcomes and interventions
What is a care plan?
Situation, background, assessment, recommendation
What is SBAR?
CA
Cancer
Updating health record
Patient right
Problem, intervention, evaluation
What is PIE?
overview of valuable patient information such as documentation, lab and test results, orders, and medications
What is Patient care summary?
Standardized, streamlined shift report system at the bedside
COPD
Chronic obstructive pulmonary disease
HIPPA
What is a law that protects confidentiality?
Data, action, response
What is DAR?
Narrative note that informs caregivers of the client
condition.
What is a progress note?
A nurse restates the orders they have been given by the healthcare provider.
What is readback?
U, u (for unit)
IU (International Unit)
Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d, qod (every other day)
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
MS
MSO4 and MgSO4
The Joint Commission Do Not Use List
Sharing a computer password with another nurse who was unable to log into the system.
Example of HIPPA breach
Only documenting significant findings.
What is charting by exception
A nurse would document here when administering a Tylenol.
What is a MAR?
A nurse reports an occurrence of a tech pulling their back lifting a patient.
What is a variance report?