hipaa
what is an example of medical records
Medical history
Description of symptoms
Diagnoses
Treatments
Prescriptions and refills
Records of patient’s telephone calls
Name of legal guardian
Name of power of attorney
5/14
what is the normal temp(F) range
97-99
behavior that shows pain
Friendly, outgoing becomes
withdrawn, weepy
Active becomes sedentary
Agitated becomes quiet,
nonverbal
Garbled speech expresses pain
clearly and succinctly
Quiet becomes noisy
first step to measuring an infant
lay the infant flat on a exam table
who is someone that may not have the right to see their medical records
patient with mental illnesses
143.05 + 22.07
165.12
normal pulse range
60-100
ways to decrease pain
Medications
Correct kinds (sometimes an anti-inflammatory works better
than a narcotic)
Rest
Heat/Ice
Comfort
Elevation
Food (for some stomach pains – ulcers)
Hydration
how is height measured
feet and inches
who do medical records belong to
health care providers and patients
what is 1/25 as a ratio
1:25
normal blood pressure (sys)
<120
what is a example of body language that shows pain
Facial expression
Crying, moaning
Rigid, guarded posture
Withdrawal when touched
Restlessness
Abnormal respirations,
breath-holding
Dilate pupils
Sweating
Favoring extremity
how is weight measured
manual or balanced scales
what must all medical records have
initials and date
what is 2:35 in military time
0235
normal bmi
18.5-24.9
what is the pain scale
0-10
how is weight measured
pounds,ounces,kilograms
errors on medical records should be covered with
single line rather than covered so its still readable
what is 6:59 in military time
1859
normal blood pressure (dias)
<80
what is another scale used to measure pain
face scale
why is head circumference measured in infants
to measure brain growth