Health Assessment, Documentation & EHR Flashcards Preview

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Flashcards in Health Assessment, Documentation & EHR Deck (24)
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1
Q

engorged, distended jugular veins reflecting increased venous pressure in the right side of the heart which, in turn, indicates an increased central venous pressure

A

Jugular Venous Distention

2
Q

high-pitched sounds heard over the trachea with expiration longer than inspiration

A

Bronchial Breath Sounds

3
Q

medium-pitched blowing sounds heard over the main stem bronchus with expiration equal to inspiration

A

Bronchovesicular Breath Sounds

4
Q

closure of mitral & tricuspid valves

A

S1 Heart Sound (Normal)

5
Q

closure of aortic & pulmonic valves

A

S2 Heart Sound (Normal)

6
Q

ventricular gallop- impending heart failure

A

S3 Heart Sound (Abnormal)

7
Q

atrial gallop

A

S4 Heart Sound (Abnormal)

8
Q

turbulent blood flow through heart

A

Murmur

9
Q

PQRST Pain Assessment

A

What PROVOKES the pain? What is the QUALITY of the pain? Does it RADIATE? What is the SEVERITY of the pain? What is the TIMING of the pain?

10
Q

method of delivering care using an interdisciplinary approach to document patient care and focusing on providing quality care in a cost-effective manner

A

Case Management Plan

11
Q

charting using a narrative format that places less emphasis on patient problems and focuses on patient concerns such as signs & symptoms, conditions, behaviors or significant event

A

Focus Charting

12
Q

similar to SOAP charting in its problem-oriented nature having a nursing origin

A

Problem, Intervention, Evaluation (PIE) Charting

13
Q

structured method of documentation that emphasizes the patient’s problems

A

Problem-Oriented Medical Record (POMR)

14
Q

method of charting using subjective data, objective data, assessment & plan

A

SOAP Charting

15
Q

innovative approach to reduce the time required to complete documentation; agency defines criteria for nursing assessments and standards of practice for nursing interventions

A

Charting By Exception (CBE)

16
Q

flip-over card file kept at nursing station providing information for the daily care of a patient

A

Kardex

17
Q

part of the permanent health record and allow documentation of certain routine observations or specific measurements made repeatedly such as height & weight, ADLs

A

Flow Sheet or Graphic Records

18
Q

reporting method using situation, background, assessment, and recommendation

A

SBAR reporting

19
Q

the most common type of record where the patient chart is separated into sections that contain forms for each discipline

A

Source-Oriented Charting (SO)

20
Q

science and art of turning data into information

A

Informatics

21
Q

a nursing specialty that manages & communicates data, information, knowledge & wisdom by integrating nursing computer and information science

A

Nursing Informatics

22
Q

A federal group formed in 2005 to advise the Secretary of the Department of Health and Human Services on methods of increasing EHR adoption in healthcare facilities.

A

American Health Information Community (AHIC)

23
Q

a set of standards, services and policies that enable secure health information exchange (HIE) over the Internet.

A

National Health Information Network (NHIN)

24
Q

an initiative that enables clinicians to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patient-centered, timely and equitable by interweaving evidence and technology seamlessly into practice, education and research fostering a learning healthcare system.

A

Technology Guiding Informatics Education Reform (TIGER)