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What components are included when documenting in a client’s medical record medical information, a plan of care, nursing documentation, medication administration records, and laboratory and diagnostic test results.
What is done when an error is made on legal hospital documents Put the word error followed by a date and initials next to the entry and immediately enter the corrected information.
source-oriented documentation records organized according to the source of documented information.
problem-oriented documentation Records organized according to the client’s health problems.
Distinguish between source-oriented documentation and problem-oriented documentation In contrast to source-oriented records that contain numerous locations for information, problem-oriented records contain four major components: the database, the problem list, the plan of care, and the progress notes.
types of documenting narrative notes, SOAP charting, focus charting, PIE charting, charting by exception, and computerized charting.
Examples of bacteria illness streptococcal sore throat, sexually transmitted infections, and tuberculosis
Examples of viruses illness herpes simplex virus, rabies, poliomyelitis, hepatitis, and AIDS
Examples of fungi illness tinea corporis (ringworm), tinea pedis (athlete’s foot), and candidiasis (a yeast infection)
Examples of rickettsiae illness Lyme disease
Principles of medical asepsis techniques Blood, body fuids, cells, and tissues are considered major reservoirs of microorganisms.sterilized equipment, hand hygiene, Personal protective equipment, clean environment,Cleaning should be done from cleaner to dirtier areas.
Principles of surgical asepsis techniques touching only sterile item,touching its not sterile, unwrapped contaminated, expiration date, time, Once opened or uncovered,
What attire worn by healthcare professionals is not approved in the hospital setting uniforms
What principles have caused bacteria to develop antibiotic resistance over prescribing, Prescribing antibiotics for viral infections, Failing to take the full course, Prescribing antibiotics for viral infections,
Best technique to sterilize sharp instruments Dry heat
Definition/Cause of opportunistic infections infectious disorders among people with compromised health - if the host’s defenses are weakened result from pathogens that, by their very nature, produce illness after invading body tissues and organs.
components in the chain of infection infectious agent, reservoir, exit route, transmission, entry, host
Identify seven uses for medical records. record of health problems,care,progress; information among health care personnel; resource for investigating the quality of care in an institution; acquire and maintain Joint Commission,reimbursement, research;legal evidence
List six components generally found in any client’s medical record.
Created by: shay7777