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Nursing > EMR > Flashcards

EMR Flashcards

1
Q

Each letter of FACT charting

A

Factual
Accurate
Complete
Timely

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2
Q

CPOE

A

Computerized Provider Order Entry

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3
Q

ABD

A

Abdomen

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4
Q

a.c.

A

Before meals

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5
Q

Ad lib

A

At liberty (client can move around freely)

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6
Q

BID

A

Twice a day

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7
Q

BK

A

Below knee

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8
Q

Cath

A

Catheter

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9
Q

CBC

A

Complete blood count

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10
Q

c/o

A

Complains of

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11
Q

C & S

A

Cultural sensitivity

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12
Q

Dx

A

Diagnosis

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13
Q

FBS

A

Fasting blood sugar

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14
Q

gtt

A

drop

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15
Q

H&H

A

Hemoglobin & hematocrit

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16
Q

Hx

A

History

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17
Q

I&O

A

Input & output

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18
Q

LMP

A

last menstrual period

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19
Q

LOC

A

Level of consiousness

20
Q

NKA

A

No known allergies

21
Q

NPO

A

Nothing by mouth

22
Q

OOB

A

Out of bed

23
Q

PRN

A

As needed

24
Q

q

A

Every

25
Q

Rx

A

Prescription

26
Q

Tx

A

Treatment

27
Q

TID

A

3 times a day

28
Q

UA

A

Urinalysis

29
Q

When can telephone prescriptions be accepted?

A

Only in emergency situations

30
Q

Which agency advocates for nationwide use of EMRs?

A

The Institute of Medicine

31
Q

Source- Orientated medical record

A

Traditional form of documentation (rarely used today)

32
Q

Which type of documentation uses SOAP for notes?

A

POMR – Problem-oriented medical record

33
Q

What does SOAP stand for?

A

Subjective
Objective
Assessment
Plan

34
Q

What does PIE stand for?

A

Problems
Interventions
Evaluations

35
Q

Which type of documentation uses DAR?

A

Focus charting

36
Q

What does DAR stand for?

A

Data
Action
Response

37
Q

5 advantages of electronic documentation.

A

Real time access to client record.

Built in clinical alerts (for i.e. contraindications)

Increased coordination of care

Allow client-provider interaction

38
Q

Write ___ instead of IU

A

International unit

39
Q

Write ___ instead of MS MSO4

A

Morphine sulfate

40
Q

Write ___ instead of per os

A

PO/by mouth

41
Q

Write ___ instead of qd

A

Daily

42
Q

Write ___ instead of qhs

A

Nightly

43
Q

Write ___ instead of qod

A

every other day

44
Q

Write ___ instead of SC

A

Subcut

45
Q

Write ___ instead of TIW

A

three times weekly

46
Q

Write ___ instead of U

A

unit

47
Q

In what situations (2) is it acceptable to repeat back a verbal prescription without writing it down first?

A

Emergency

Sterile environment

Nursing (12 decks)

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