Recording and Reporting, Vitals, Physical Assessment
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| Uses of Medical Records | Share info among health care workers; investigate quality of care
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| Shift Change Report | Discussion between nursing staff at the end of one shift and beginning of another
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| Legally defensible charting | Never scribble over entries or use correction fluid; leave no empty spaces or lines between entries and signature; sign each entry with name and title
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| Narrative charting | style generally used in source-oriented records; involves writing information about the client and care in chronological order
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| SOAP charting | more likely used in problem-oriented record; 4 essential components:
S-subjective data
O- objective data
A- analysis of data
P- plan for care
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| Focus charting | modifies SOAP; used focus rather that problem; data, action, response
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| PIE charting | problem, intervention, evaluation
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| Charting by exception | chart only abnormal assessment findings or care that deviated from standard
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| Computerized Charting | documented client information electronically
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| Kardex | quick reference for current information about the client and care
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| Nursing care plan | written list of client's problems, goals, and nursing orders for client care.
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| subnormal body temperature | hypothermia; less than 95 degrees F
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| treatment of subnormal temp | raise room temp; remove wet clothing; apply layers of dry clothing; warm blankets; position patient so arms are next to chest and legs are tucked towards abdomen; cover heard with cap or towel;warm fluids; apply warm water bags; massage skin
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| hypothalamus | temperature regulating part of the brain
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| What can influence core body temperatures? | Food intake (protein=higher)
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| Factors affecting body temp | Age, climate, gender, exercise, circadian rhythm, emotions, illness or injury, medications,
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| Infants body temperatures | difficulty maintaining body temp, experience temperature fluctuations because they have 3x greater surface area where heat is lost
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| Best way to monitor temp | ear
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