EXAM 1 Flashcards
(377 cards)
Reporting
oral communication about a patients status
Documentation
The act of recording patient status and care in written or electronic form, or in combination of the 2 forms
medical record/ health record
historically, the collection of documentation, orders, and other care information for a patient
Clear complete and accurate documentation in a clients health record serves a variety of purposes
communication
legal record
continuity of care
quality improvement
health record system
the overall process by which all patient records are created, stored, and retrieved in an organization
Source-oriented system
members of each discipline record their findings in a separately labeled section of the chart
Problem-oriented records (PROs)
organized around the patient’s problems
Charting by exception
a system of charting in which only significant findings or exceptions to standards and norms of care are charted
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
Disadvantages of electronic health records
Expense
Downtime
Lack of integration
Difficulties associated with change
ADLs
Activities of Daily Living
ad lib
As desired, if the patient desires
AKA
Above-knee amputation
Amb
Ambulation, ambulatory
Amt
Amount
bid
twice a day
BM
bowel movement
BR
bedrest
BRP
bathroom privileges
BSC
bedside commode
c
calories
cath
catheter
CBC
complete blood count
CCU
critical care unit
coronary care unti