Funda Rle Flashcards
It is a formal, legal document that provides evidence of a client’s care.
Client’s Record/Patient’s Chart
It is a complete record of a patient’s key clinical data and medical history, such as
demographics, vital signs, diagnoses, medications, treatment plans, progress notes,
problems, immunization dates, allergies, radiology images, and laboratory and test
results.
Client’s Record/Patient’s Chart
Give a 8 purpose of Client’s Record/Patient’s Chart
- Communication
- Planning client care
- Auditing health agencies
4.Research - Education
- Reimbursement
- Legal documentation
- Health care analysis
Give 12 Components of patient’s charts
- Admission sheet
- Physician’s order sheet
- Nurse’s admission assessment
- Graphic sheet and flow sheet
- Medical history and examination
- Nurses’ notes
- Medication records
- Physicians progress notes
- Health care discipline’s records
10.discharge summary - TPR sheet
- Labor sheet
It contains Legal name, birthdate, age, gender
o Social security number
o Address
o Marital status; closest relatives or person to notify in case of emergency
o Date, time, and admitting diagnosis
o Food or drug allergies
o Name of admitting (attending) physician
o Insurance information (if any)
o Any assigned diagnosis-related group (DRG
Admission (face) sheet
It contains record of physician’s orders for treatment and medications, with date, time and
physician’s signature
Physician’s Order Sheet
It contains Summary of nursing history and physical assessment
Nurse’s Admission Assessment
It contain Record of repeated observations and measurements such as vital signs, daily
weights, and intake and output
Graphic Sheet and Flow Sheet
It contains Results of initial examination performed by physician, including findings, family
history, confirmed diagnosis, and medical plan of care
Medical History and Examination
It Narrative record of nursing process: assessment, nursing diagnosis, planning,
implementation, and evaluation of care
o FDAR, SOAPIE
Nurses’ Notes
It contains Accurate documentation of all medications administered to client: date, time,
dose, route, and nurse’s signature
Medication records
It contains Ongoing record of client’s progress and response to medical therapy and review
of the disease process
Physician’s Progress Notes
It contain Entries made into record by all health-related disciplines: radiology, social work,
and laboratories
Health Care discipline’s records
It contain Summary of client’s condition, progress, prognosis, rehabilitation, and teaching
needs at time of dismissal from hospital or health care agency
Discharge summary
It contains It is flow sheet to show patient clinical information for physicians to judge
patient condition
o It contains temperature, respiratory rate, pulse rate, input and output of the
patient
TPR sheet
It contain For patients admitted who are in labor
o Fetal heart is being monitored as well as the vital signs of the patient
Labor sheet
Also known as cardinal sign.
- it reflect the physiological status of the body
- it provide information critical to evaluating the body’s homeostatic balance.
Vital signs
- They are four critical assessment area, of vital sign.
- These four signs form baseline evaluative data necessary for ongoing evaluation of a patient’s
- Body temperature
- Pulse rate
- Respiration rate
- Blood pressure,
Additional: - pain
It used because the information gathered is the clearest indicator for normal patient status.
Vital, the term vital
- It represents the balance between heat gain, heat loss and It is regulated in the hypothalamus of the brain.
- It is measured by a clinical thermometer.
•Temperature
- Temperature indicate the health status of the body.
- This may be due to pyrogens, nervous system disease, or injury.
Variations of temperature
There are two kinds of body temperature:
•Core temperature
• Surface temperature
- temperature of the deep tissues.
Such as the abdominal cavity and pelvic cavity. - remains relatively constant.
•Core temperature
The temperature of the skin, the subcutaneous tissue and fat.
• Surface temperature
