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Patient Care Rounds: Postoperative Question and Ansers2024 Clarity use precise medical terminology Completeness the chart must contain all pertinent information Conciseness abbreviations use when possible, helps to save time and space Chronological orde$5.39
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Patient Care Rounds: Postoperative Question and Ansers2024 Clarity use precise medical terminology Completeness the chart must contain all pertinent information Conciseness abbreviations use when possible, helps to save time and space Chronological orde
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Course
Patient Care Rounds: Postoperative
Institution
Patient Care Rounds: Postoperative
Patient Care Rounds: Postoperative Question and
Ansers2024
Clarity
use precise medical terminology
Completeness
the chart must contain all pertinent information
Conciseness
abbreviations use when possible, helps to save time and space
Chronological order
date all entries
Confidentiality...
Patient Care Rounds: Postoperative Question and
Ansers2024
Clarity
use precise medical terminology
Completeness
the chart must contain all pertinent information
Conciseness
abbreviations use when possible, helps to save time and space
Chronological order
date all entries
Confidentiality
protect the patient's privacy.
Questions to ask when making a pain assessment
When did the pain start; Where is the pain; How often do you feel the pain; Does anything
you do kessen the pain; Describe the pain
, You suspect a patient is being abused
He/She has bruises all over their body. The explanation given regarding those bruises is weak.
patient's medical record should have these documentations in each patient's medical record:
Patient registration form; Patient medical history; Physical exam results; Lab and test results;
copies of RX's and refill request; DX and treatment plan; progress note, phone calls, consent
forms
Narrative style charting
When physicians dictate notes about patient care, then have those notes transcribed and
placed in the patient's files
SOAP note
is an acronym that stands for subjective, objective, assessment, and plan.
Problem-oriented medical record charting
POMR, is a method of tracking the patient's problems during the time they are receiving
medical care
Progress notes
are daily chart notes which are used to record any information that pertains to the various
stages of a patient's condition
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