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Documentation

The act of recording patient status and care in written or electronic form, or in combination of the 2 forms

1

Reporting

oral communication about a patients status

2

medical record/ health record

historically, the collection of documentation, orders, and other care information for a patient

3

Clear complete and accurate documentation in a clients health record serves a variety of purposes

communication
legal record
continuity of care
quality improvement

4

health record system

the overall process by which all patient records are created, stored, and retrieved in an organization

5

Source-oriented system

members of each discipline record their findings in a separately labeled section of the chart

6

Problem-oriented records (PROs)

organized around the patient's problems

7

Charting by exception

a system of charting in which only significant findings or exceptions to standards and norms of care are charted

8

Advantages of electronic records systems

Enhanced communication and collaboration among healthcare providers
Improved access to information
Time savings
Improved quality of care
Information is private and safe

9

Disadvantages of electronic health records

Expense
Downtime
Lack of integration
Difficulties associated with change

10

ADLs

Activities of Daily Living

11

ad lib

As desired, if the patient desires

12

AKA

Above-knee amputation

13

Amb

Ambulation, ambulatory

14

Amt

Amount

15

bid

twice a day

16

BM

bowel movement

17

BR

bedrest

18

BRP

bathroom privileges

19

BSC

bedside commode

20

c

calories

21

cath

catheter

22

CBC

complete blood count

23

CCU

critical care unit
coronary care unti

24

c/o

complaint of

25

CO2

carbon dioxide

26

CPR

cardiopulmonary resuscitation

27

CVA

cerebrovascular accident (stroke)

28

D&C

dilation and curettage

29

DM

diabetes mellitus