Chapter 17

Question 1

The act of recording patient status and care?

Answer 1

Documentation

Question 2

What are the four C’s of documenting?

Answer 2

Clear, concise, correct, complete

Question 3

____ _____ is used to determinate whether the medical treatments and interventions were necessary and appropriate.

Answer 3

Utilization review

Question 4

A system of charting in which you only document significant findings or exceptions to standards and norms of care.

Answer 4

Charting by exception

Question 5

Type of chart entry that tells the story of the client’s experience in the order that it happens

Answer 5

Narrative chart entry

Question 6

When you are only charting things outside of normal limits?

Answer 6

Charting by exception

Question 7

BM

Answer 7

bowel movement

Question 8

BR

Answer 8

bed rest

Question 9

c/o

Answer 9

complaint of

Question 10

D&C

Answer 10

Dilation and Curettage

Question 11

DM

Answer 11

diabetes militus

Question 12

EBL

Answer 12

estimated blood loss

Question 13

EENT

Answer 13

ears, eyes, nose, throat

Question 14

AKA

Answer 14

above knee amputation

Question 15

Amt

Answer 15

amount

Question 16

BRP

Answer 16

bathroom privelages

Question 17

CVA

Answer 17

Cerebrovascular accident (stroke)

Question 18

dsg

Answer 18

dressing

Question 19

ETOH

Answer 19

alcohol

Question 20

FBS

Answer 20

fasting blood sugar

Question 21

GYN

Answer 21

gynecology

Question 22

GU

Answer 22

Genitourinary

Question 23

HA

Answer 23

headache

Question 24

HTN

Answer 24

hypertension

Question 25

LMP

Answer 25

last menstrual period

Question 26

MN

Answer 26

midnight

Question 27

NAS

Answer 27

no added salt

Question 28

OOB

Answer 28

out of bed

Question 29

R/O

Answer 29

rule out

Question 30

SCD

Answer 30

sequential compression device

Question 31

SSE

Answer 31

soapsuds enema

Question 32

TO

Answer 32

telephone order

Question 33

TPR

Answer 33

temperature, pulse, respirations

Question 34

w/c

Answer 34

wheelchair

Question 35

WNL

Answer 35

within normal limits

Question 36

TB

Answer 36

tuberculosis

Question 37

s-

Answer 37

without

Question 38

qam

Answer 38

every morning