Vital Signs and Critical Ranges
This is the normal adult body temperature in Fahrenheit.
What is 98.6°F?
The term ''tachypnea'' refers to this condition.
What is rapid breathing?
The chief complaint is best defined as this.
What is the primary reason the patient seeks medical care?
The ''S'' in SAMPLE stands for this.
What is Signs and Symptoms?
All patient documentation must be this to ensure legal and professional accuracy.
What is clear, concise, and factual?
A pulse rate below 60 beats per minute is called this.
What is bradycardia?
The prefix ''hypo-'' means this.
What is below or deficient?
This is the best way to document a patients chief complaint.
What is using the patient's own words in quotation marks?
The ''O'' in OPQRST refers to this aspect of pain assessment.
What is Onset?
The acronym is used to structure nursing or EMS documentation effectively.
What is SOAP (Subjective, Objective, Assessment, Plan)?
Normal adult respiratory rate per minute.
What is 12-20 breaths per minute?
The suffix ''-itis'' indicates this.
What is inflammation?
When a patient reports ''chest pain'' this follow up question helps clarify the complaint.
What is ''can you describe the pain?''
The ''A'' in SAMPLE refers to this patient information?
What are Allergies?
This type of error should never be erased but corrected with a single line and initials.
What is a written documentation error?
A blood pressure reading of 90/60 mmHg or lower is considered this.
What is hypotension?
The term ''cyanosis'' describes this physical finding.
What is bluish discoloration due to lack of oxygen?
This type of questioning technique helps gather more specific details about the chief complaint.
What is open-ended questioning?
The ''R'' in OPQRST helps identify this characteristic of pain.
What is Radiation (where the pain moves)?
This principle ensures that only those directly involved in patient care can access records.
What is confidentiality or HIPAA compliance?
An oxygen saturation below this percentage is considered critical and may require intervention.
What is 90%?
The term ''orthopnea'' refers to this symptom.
What is difficulty breathing while laying back?
If a patient cannot verbalize a complaint, this method is used to determine the chief concern.
What is observation and caregiver input?
The ''E'' in SAMPLE stands for this and helps identify what led to the current condition.
What are Events leading up to the illness or injury?
This documentation method records findings in the order they occur during assessment.
What is chronological documentation?