Chapter 4 & 5—Documentation & General Survey Flashcards
(10 cards)
1
Q
documentation must be…
A
accurate, clear, objective, concise, complete, legible
2
Q
SBAR purpose
A
model for improving communication between clinicians
3
Q
SBAR components
A
Situation
Background
Assessment
Recommendation
4
Q
HIPPA
A
Health Insurance Portability & Accountability Act
5
Q
in general survey, first…
A
understand how to tell if a pt needs an urgent assessment
6
Q
series of quantitative measurements of the muscle, bone, and adipose tissue used to assess the composition of the body
A
Anthropometric measurements
7
Q
ecto, meso, endomorph
A
ecto - underweight
meso - athletic
endo - overweight
8
Q
more prone to T2DM & CVD (apple or pear)
A
pear
9
Q
mobility - observe…
A
gait, posture, ROM
10
Q
behavior - observe…
A
dress and grooming, body odors, facial expression, mood and affect, eye contact, anxiety
