Charting.txt

Records pertinent patient information (e.g., name, address, religion, nearest of kin), admitting physician, and admission diagnosis

Records the patient's admitting history and physical examination, as performed by the attending physician or resident

Records the physician's orders and prescriptions

Keeps a continuing account of the patient's progress for the physician

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

Notes drugs and intravenous fluids that are given to the patient

Records the patient's temperature, pulse, respirations, and blood pressure over time

Records patient's fluid intake (I) and output (O) over time

Summarizes the results of laboratory tests

Records notes by physicians who are called in to examine a patient to make a diagnosis

Records the patient's authorization for surgery or treatment

Notes key events before, during, and immediately after surgery

Records specialized treatments or treatment plans and patient progress for various specialized therapeutic services (e.g., respiratory care, physical therapy)

Entries on the patient's chart should be printed or _______.

After completing the account, sign the chart with ____ and your _____ and your title

Do not use ____ marks.

What can be used against you in a Court of Law?

If a mistake is made, a single line should be drawn through the mistake and the word "___" printed above it.

Record after completing each task for the patient and __________ correctly after each entry.

Be exact in noting the _____, ____, and _____ of all treatments and procedures.

Chart patient ____ and general behavior.

Describe the _____, _____, _____, and _____ of pain.

Describe clearly and concisely the ______ and of secretions.

Leave no ___________ in the charting.

You should always make sure to use what abbreviations?

Use which tense when charting?

What should you always make sure to do when writing in a chart?

CDocument conversations with the ______ or other ________________ that you feel are important.