N202 Guidelines for recording the database

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What are significant "positives"?

Signs and symptoms that are present; they are recorded first
What are significant negatives?

Signs and symptoms not present; recorded after significant positives
Format for recording the database?
- a) use headlines to delineate topics
- b) record subjective information in narrative style
- c) use short phrases
- d) use quotes only when helpful conveying message
- e) use appropriate medical terminology
- f) data should be measureable quantifiable
- g) avoid vague terms ie "good" "normal"
How to note an error in documentation

put a line through data and initial it
Medical record is considered a......

legal document ( if it wasnt written down it was not done)
Physical examination order for the body besides the abdomen
- a) inspection
- b)palpation
- c) percussion
- d)auscultation
Physical examination order for the abdomen
- a) inspection
- b) ausculation
- c)percussion
- d) palpation
Always include presence or absence of constitutional symptoms when appropriate. Examples....
- fever, chills, sweats (f/v/s)
- nausea, vomiting, diarrhea (n/v/d)
- weight loss
Reason for use of scales
- Helps quantify measures (include the limits)
- ie. pain (4/10) 0= no pain/ 10=severe pain)
When are diagrams appropriate?

When they clarify and simplify descriptions and findings

Author

40979

Card Set

N202 Guidelines for recording the database

Description

SDSU N202 Guidelines for recording the database

Updated

2010-10-10T19:18:59Z

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