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1423
EXAM 1 BLUEPRINT
| Question | Answer |
|---|---|
| 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
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