chapter 4 - medical soap notes

21問 • 2年前

Flinch Eidref Liongson

通報

問題一覧

relate to information that you obtain directly

objective observations

relate to information that you cannot detect with one of your five senses

subjective observations

sometimes reffered to as charting

recording

legal document where information about the person's currect condition

medical record

provides standard information about the person, including the person's name, address, date of birth and age

admission sheet

the medical record contains dictated and typed medical history from the person's doctor

medical history

completed by the nurse at the time of the person's admission to the facility

nursing history

used by the doctor to communicate to the other member of the health care team

physicians order sheet

the medication ordered for the patient or resident are listed here, along with the dosage

medication administration record

The doctor uses this form to record his notes and observations about the person's progress

physicians progress notes

the nurse uses this form to document the person's complaints and actions by the nursing staff

narrative nurses notes

this is where information that is gathered routinely

graphic sheet

laboratory reports, radiology reports and reports related to other diagnostic tests or therapeutic treatments

miscellaneous documents

a card file, containing condesed versions if each patients or residents medical record

kardex

collection of techniques that prioritize the physical mental and emotional well being of the patient

therapeutic communication

the ideas, customs and social behavior of a particular people or society

culture

the ability to understand and interact effectively

cultural competence

usually indicates cultural heritage, the experience shared by people who have a common ancestral origin

ethnicity

a category of human kind that shares certain physical traits

race

the understanding that our own culture beliefs from one individual and group to the next

cultural awareness

something that you notice about the patient or resident

observation

Quiz Chapter 1-3

Flinch Eidref Liongson · 100問 · 2年前

Quiz Chapter 1-3

100問 • 2年前

Flinch Eidref Liongson

chapter 4 abbreviation

Flinch Eidref Liongson · 71問 · 2年前

chapter 4 abbreviation

71問 • 2年前

Flinch Eidref Liongson

chapter 4 medical terminology

Flinch Eidref Liongson · 25問 · 2年前

chapter 4 medical terminology

25問 • 2年前

Flinch Eidref Liongson

Quiz 4 chain of communication

Flinch Eidref Liongson · 10問 · 2年前

Quiz 4 chain of communication

10問 • 2年前

Flinch Eidref Liongson

quiz 4 directional references

Flinch Eidref Liongson · 8問 · 2年前

quiz 4 directional references

8問 • 2年前

Flinch Eidref Liongson

chapter 5 cells

Flinch Eidref Liongson · 9問 · 2年前

chapter 5 cells

9問 • 2年前

Flinch Eidref Liongson

chapter 5 tissue

Flinch Eidref Liongson · 10問 · 2年前

chapter 5 tissue

10問 • 2年前

Flinch Eidref Liongson

chapter 5 intergumentary system

Flinch Eidref Liongson · 8問 · 2年前

chapter 5 intergumentary system

8問 • 2年前

Flinch Eidref Liongson

chapter 5 circulatory system

Flinch Eidref Liongson · 8問 · 2年前

chapter 5 circulatory system

8問 • 2年前

Flinch Eidref Liongson

問題一覧

relate to information that you obtain directly

objective observations

relate to information that you cannot detect with one of your five senses

subjective observations

sometimes reffered to as charting

recording

legal document where information about the person's currect condition

medical record

provides standard information about the person, including the person's name, address, date of birth and age

admission sheet

the medical record contains dictated and typed medical history from the person's doctor

medical history

completed by the nurse at the time of the person's admission to the facility

nursing history

used by the doctor to communicate to the other member of the health care team

physicians order sheet

the medication ordered for the patient or resident are listed here, along with the dosage

medication administration record

The doctor uses this form to record his notes and observations about the person's progress

physicians progress notes

the nurse uses this form to document the person's complaints and actions by the nursing staff

narrative nurses notes

this is where information that is gathered routinely

graphic sheet

laboratory reports, radiology reports and reports related to other diagnostic tests or therapeutic treatments

miscellaneous documents

a card file, containing condesed versions if each patients or residents medical record

kardex

collection of techniques that prioritize the physical mental and emotional well being of the patient

therapeutic communication

the ideas, customs and social behavior of a particular people or society

culture

the ability to understand and interact effectively

cultural competence

usually indicates cultural heritage, the experience shared by people who have a common ancestral origin

ethnicity

a category of human kind that shares certain physical traits

race

the understanding that our own culture beliefs from one individual and group to the next

cultural awareness

something that you notice about the patient or resident

observation