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Fund. of Nursing
Documentation
| Question | Answer |
|---|---|
| Legally Safe Documentation | *Too Long* PG. 50 |
| Protection of private health information (HIPAA) | Protects patients' private health information. Governs all areas of health information management. PG. 52 Provides standards for the protection of electronic health information. |
| Common Record-Keeping Forms or Screens | 1. Admission Nursing History Forms 2. Flow Sheet and Graphic Records 3. Patient Education Record 4. Patient Care Summary or Kardex 5. Acuity Records 6. Standardized Care Plans 7. Discharge Summaries PG. 55-57 |
| Purposes of nursing documentation | 1. Ensures continuity of care, provides legal evidence, and evaluates patient outcomes. 2. Provides a detailed account of a patient's plan of care, important assessment, and treatment, which must be an accurate and timely evaluation of information. |
| Recognize appropriate circumstances for documenting patient data | *Too Long* PG. 61 |
| Documenting Nurses' Progress Notes | *Too Long* PG. 61 |
| Adverse Event Reporting | *Too Long* PG. 62 |
| Standard components of documentation | *Too Long* PG. 53 |
| Documentation formats for (progress notes) | 1. SBAR 2. SOAP 3. PIE 4. Focus Charting "DAR" (Data, Action, & Response) PG. 58-59 |
| a | before |
| abd | abdomen |
| ac | before meals |
| ad lib | as desired or as freely as desired |
| AKA | above the knee amputation |
| a.m.a. | against medical advice |
| AP | apical pulse or anterior and posterior |
| ASA | aspirin or acetyl salicylic acid |
| ax | axillary |
| bid | two times a day |
| BKA | below the knee amputation |
| BP | blood pressure |
| BPH | benign prostatic hypertrophy |
| BR | bedrest |
| BRP | bathroom privileges |
| BSC | bedside commode |
| c | with |
| cath | catheter or catheterize |
| cm | centimeter |
| c/o | complains of or complaint of |
| CPM | continuous passive motion |
| CXR | chest x-ray |
| DOE | dyspnea on exertion |
| ECG; EKG | electrocardiogram |
| EGD | esophagogastroduodenoscopy |
| EOM | extra-ocular movements |
| ER | extended release or Emergency Room |
| FSBS | finger stick blood sugar |
| f/u | follow up |
| g; gm; Gm | gram |
| GI | gastrointestinal |
| gr | grain |
| gtt | drop or drops |
| H/A | headache |
| h/o | history of |
| HOB | head of bed |
| HOH | hard of hearing |
| HR | heart rate |
| hs | at bedtime |
| ID | intradermal |
| IM | intramuscular |
| IS | incentive spirometry |
| IV | intravenous |
| IVP | intravenous push |
| JVD | jugular vein distention |
| K+ | potassium |
| Kg | kilogram |
| L; l | liter |
| LLL | left lower lobe |
| LLQ | left lower quadrant |
| LMP | last menstrual period |
| LOC | level of consciousness |
| LUL | left upper lobe |
| LUQ | left upper quadrant |
| mcg | microgram |
| meq | milliequivalent |
| mg | milligram |
| Mg | magnesium |
| ml | millileter |
| mm | millimeter |
| MRSA | methicillin resistant staph aureus |
| Na | sodium |
| NaCl | sodium chloride |
| neg | negative |
| NG | nasogastric |
| NKA | no known allergies |
| NKDA | no known drug allergies |
| NPO | nothing by mouth |
| NS | normal saline |
| O2 | oxygen |
| OOB | out of bed |
| p | after |
| P | pulse |
| pc | after meals |
| PCN | penicillin |
| PERRLA | pupils equal, round, reactive to light and accommodation |
| PICC | peripherally inserted central catheter |
| po | by mouth |
| POD | post-operative day |
| pos | positive |
| postop | postoperative or after sugery |
| preop | preoperative or before surgery |
| prn | as needed |
| pt; Pt | patient |
| PT | physical therapy |
| q | every |
| qid | four times a day |
| quad | quadrant |
| R | respirations |
| RLL | right lower lobe |
| RLQ | right lower quadrant |
| RML | right middle lobe |
| R/O | rule out |
| ROM | range of motion |
| RRR | regular rate and rhythm |
| r/t | related to |
| RT | respiratory therapist/therapy |
| RUL | right upper lobe |
| RUQ | right upper quadrant |
| s | without |
| SL;sl | sublingual |
| SNF | skilled nursing facility |
| SOB | shortness of breath |
| s/p | status post |
| s/s | signs and symptoms |
| STAT | immediately |
| Subcut | subcutaneous |
| supp | suppository |
| susp | suspension |
| T | temperature |
| TCDB | turn, cough, deep breathe |
| Tid | three times a day |
| TKO | to keep open |
| TPR | temperature, pulse, respirations |
| Up ad lib | up as desired or up freely as desired |
| VS | vital signs |
| VTBI | volume to be infused |
| W/A | while awake |
| WNL | within normal limits |
| Wt | weight |
| JCAHO "Forbidden" Abbreviations | *On Sheet* |
Created by:
Megan123456
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