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Standing Orders A predetermined plan of care which may include a specific series of blood tests, x-rays, and urinalysis. It may also consist of a set of preoperative or pretherapy activities.
Doctor’s Orders. The doctor’s instructions for lab tests, radiology exams, consultations and medications are all contained in a separate data collection.
Plan Treatment or further diagnostic evaluation.
Assessment Physician’s opinion as to the diagnosis or possible diagnoses.
Objective Physician’s observations, including evaluation of diagnostic test results.
Subjective Patient’s report of symptoms or problems.
Vital Signs Includes the patient’s temperature, blood pressure, pulse, and respiration.
Pulse Rate that the blood flows through a person’s artery.
Pulse Rate Consist of the number of heartbeats per minute.
Nursing Assessment It’s not to diagnose the patient’s illness- that is the physician’s responsibility- but to diagnose the patient’s care needs.
Discharge Summary This is done when a patient is an inpatient setting. It includes a brief history, a discharge diagnosis, and additional findings.
Progress Notes While a patient is being treated, the physician makes continuing observations and updates the assessment and plan.
Problem-Oriented Organizing all of the data by the patient’s diagnosis or problem.
Date-Oriented When the first piece of data is recorded with its date, and each subsequent piece of data is organized in date order.
Source-Oriented All of the data from the physician can be grouped together, all of the data from the nurse can be grouped together and all of the info from the lab can be grouped together.
History Taken from the data that the patient reports to the physician regarding the patient’s health.
Respiration Count the Number of times the chest rise & fall.
Authorization Giving permission to release information or permission to perform a certain procedure.
HIPAA Its original goal was to make it easier for people to move from one health insurance plan to another as they change jobs or become unemployed.
HIPAA Health Insurance Portability and Accountability Act of 1996.
Created by: Mackey1