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Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, and admission diagnosis
Admission Sheet
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Records the patient's admitting history and physical examination, as performed by the attending physician or resident
History and Physical Examination
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Records the physician's orders and prescriptions
Physician's Orders
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Keeps a continuing account of the patient's progress for the physician
Progress Sheet
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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
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Notes drugs and intravenous fluids that are given to the patient
Medication Record
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Records the patient's temperature, pulse, respirations, and blood pressure over time
Vital Signs Graphic Sheet
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Records patient's fluid intake (I) and output (O) over time
I/O Sheet
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Summarizes the results of laboratory tests
Laboratory Sheet
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Records notes by physicians who are called in to examine a patient to make a diagnosis
Consulation Sheet
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Records the patient's authorization for surgery or treatment
Surgical or Treatment Consent
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Notes key events before, during, and immediately after surgery
Anesthesia and Surgical Record
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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
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Entries on the patient's chart should be printed or _______.
handwritten
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After completing the account, sign the chart with ____ and your _____ and your title
one initial; last name
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Do not use ____ marks.
ditto
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What can be used against you in a Court of Law?
Erasesures
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If a mistake is made, a single line should be drawn through the mistake and the word "___" printed above it.
error
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Record after completing each task for the patient and __________ correctly after each entry.
sign your name
-
Be exact in noting the _____, ____, and _____ of all treatments and procedures.
time; effect; results
-
Chart patient ____ and general behavior.
complaints
-
Describe the _____, _____, _____, and _____ of pain.
type; location; onset; duration
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Describe clearly and concisely the ______ and of secretions.
character; amount
-
Leave no ___________ in the charting.
blank lines
-
You should always make sure to use what abbreviations?
standard
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Use which tense when charting?
- Present
- i.e. "Patient to receive treatment after lunch."
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What should you always make sure to do when writing in a chart?
Spell correctly, use a dictionary if you are unsure
-
CDocument conversations with the ______ or other ________________ that you feel are important.
patient; health care providers
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