Busy. Please wait.

show password
Forgot Password?

Don't have an account?  Sign up 

Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove Ads
Don't know
remaining cards
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
restart all cards

Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how



Malpractice mistakes that are common on charting failing to: 1) record pertinent health/drug info 2) record nursing actions 3) record meds given 4) drug reactions or changes in clients condition 5) writing illegible or complete records 6) to document a discontinued medication
purposes of records 1) communication 2) legal documentation 3) financial billing 4) education 5) research 6) auditing-monitoring
Confidentiality 1) pt. educ. on privacy protection 2) ensuring pt. access to their medical records 3) rcing pt. consent before info is released 4) providing recourse if privacy protection are violated
quality of documentation factual, accurate, complete, current, organized
SOAP subjective, objective, assessment, plan
SOAPIE subjective, objective, assessment, plan, intervention, evaluation
PIE problem, intervention, evaluation
Focus charting - DAR data, action, response
Problem-Oriented Medical Records (POMR) database, problem list, nursing care plan, progress notes
Organization of Traditional Source Record -Admission sheet -Physician's order sheet -Nurse's admission assessment -Graphic sheet & flow sheet -Medical history & examination -Nurses' notes -medication records -Physician's progress notes -health care disciplines' records -discharges summar
SBAR Situation, Background, Assessment, Recommendation
Created by: chinkychunsa