Flashcards in EXAM 1 Deck (377)
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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
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Reporting
oral communication about a patients status
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medical record/ health record
historically, the collection of documentation, orders, and other care information for a patient
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Clear complete and accurate documentation in a clients health record serves a variety of purposes
communication
legal record
continuity of care
quality improvement
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health record system
the overall process by which all patient records are created, stored, and retrieved in an organization
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Source-oriented system
members of each discipline record their findings in a separately labeled section of the chart
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Problem-oriented records (PROs)
organized around the patient's problems
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Charting by exception
a system of charting in which only significant findings or exceptions to standards and norms of care are charted
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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
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Disadvantages of electronic health records
Expense
Downtime
Lack of integration
Difficulties associated with change
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ADLs
Activities of Daily Living
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ad lib
As desired, if the patient desires
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AKA
Above-knee amputation
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Amb
Ambulation, ambulatory
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Amt
Amount
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bid
twice a day
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BM
bowel movement
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BR
bedrest
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BRP
bathroom privileges
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BSC
bedside commode
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c
calories
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cath
catheter
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CBC
complete blood count
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CCU
critical care unit
coronary care unti
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c/o
complaint of
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CO2
carbon dioxide
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CPR
cardiopulmonary resuscitation
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CVA
cerebrovascular accident (stroke)
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D&C
dilation and curettage
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