Question | Answer |
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. |