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The flashcards below were created by user
Bethanrg
on FreezingBlue Flashcards.
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What are significant "positives"?
Signs and symptoms that are present; they are recorded first
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What are significant negatives?
Signs and symptoms not present; recorded after significant positives
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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"
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How to note an error in documentation
put a line through data and initial it
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Medical record is considered a......
legal document ( if it wasnt written down it was not done)
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Physical examination order for the body besides the abdomen
- a) inspection
- b)palpation
- c) percussion
- d)auscultation
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Physical examination order for the abdomen
- a) inspection
- b) ausculation
- c)percussion
- d) palpation
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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
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Reason for use of scales
- Helps quantify measures (include the limits)
- ie. pain (4/10) 0= no pain/ 10=severe pain)
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When are diagrams appropriate?
When they clarify and simplify descriptions and findings
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