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  1. Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, and admission diagnosis
    Admission Sheet
  2. Records the patient's admitting history and physical examination, as performed by the attending physician or resident
    History and Physical Examination
  3. Records the physician's orders and prescriptions
    Physician's Orders
  4. Keeps a continuing account of the patient's progress for the physician
    Progress Sheet
  5. Describes the nursing care given to the patient, including the patient's complaints (subjective symptoms), the nurses' observations (objective signs), and the patient's response to therapy
    Nurses' Notes
  6. Notes drugs and intravenous fluids that are given to the patient
    Medication Record
  7. Records the patient's temperature, pulse, respirations, and blood pressure over time
    Vital Signs Graphic Sheet
  8. Records patient's fluid intake (I) and output (O) over time
    I/O Sheet
  9. Summarizes the results of laboratory tests
    Laboratory Sheet
  10. Records notes by physicians who are called in to examine a patient to make a diagnosis
    Consulation Sheet
  11. Records the patient's authorization for surgery or treatment
    Surgical or Treatment Consent
  12. Notes key events before, during, and immediately after surgery
    Anesthesia and Surgical Record
  13. Records specialized treatments or treatment plans and patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy)
    Specialized Therapy Records/Progress Notes
  14. Entries on the patient's chart should be printed or _______.
  15. After completing the account, sign the chart with ____ and your _____ and your title
    one initial; last name
  16. Do not use ____ marks.
  17. What can be used against you in a Court of Law?
  18. If a mistake is made, a single line should be drawn through the mistake and the word "___" printed above it.
  19. Record after completing each task for the patient and __________ correctly after each entry.
    sign your name
  20. Be exact in noting the _____, ____, and _____ of all treatments and procedures.
    time; effect; results
  21. Chart patient ____ and general behavior.
  22. Describe the _____, _____, _____, and _____ of pain.
    type; location; onset; duration
  23. Describe clearly and concisely the ______ and of secretions.
    character; amount
  24. Leave no ___________ in the charting.
    blank lines
  25. You should always make sure to use what abbreviations?
  26. Use which tense when charting?
    • Present
    • i.e. "Patient to receive treatment after lunch."
  27. What should you always make sure to do when writing in a chart?
    Spell correctly, use a dictionary if you are unsure
  28. CDocument conversations with the ______ or other ________________ that you feel are important.
    patient; health care providers
Card Set
Crafton Hills College Resp 131 Charting
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