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Flashcards in Health Assessment, Documentation & EHR Deck (24)
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1

engorged, distended jugular veins reflecting increased venous pressure in the right side of the heart which, in turn, indicates an increased central venous pressure

Jugular Venous Distention

2

high-pitched sounds heard over the trachea with expiration longer than inspiration

Bronchial Breath Sounds

3

medium-pitched blowing sounds heard over the main stem bronchus with expiration equal to inspiration

Bronchovesicular Breath Sounds

4

closure of mitral & tricuspid valves

S1 Heart Sound (Normal)

5

closure of aortic & pulmonic valves

S2 Heart Sound (Normal)

6

ventricular gallop- impending heart failure

S3 Heart Sound (Abnormal)

7

atrial gallop

S4 Heart Sound (Abnormal)

8

turbulent blood flow through heart

Murmur

9

PQRST Pain Assessment

What PROVOKES the pain? What is the QUALITY of the pain? Does it RADIATE? What is the SEVERITY of the pain? What is the TIMING of the pain?

10

method of delivering care using an interdisciplinary approach to document patient care and focusing on providing quality care in a cost-effective manner

Case Management Plan

11

charting using a narrative format that places less emphasis on patient problems and focuses on patient concerns such as signs & symptoms, conditions, behaviors or significant event

Focus Charting

12

similar to SOAP charting in its problem-oriented nature having a nursing origin

Problem, Intervention, Evaluation (PIE) Charting

13

structured method of documentation that emphasizes the patient's problems

Problem-Oriented Medical Record (POMR)

14

method of charting using subjective data, objective data, assessment & plan

SOAP Charting

15

innovative approach to reduce the time required to complete documentation; agency defines criteria for nursing assessments and standards of practice for nursing interventions

Charting By Exception (CBE)

16

flip-over card file kept at nursing station providing information for the daily care of a patient

Kardex

17

part of the permanent health record and allow documentation of certain routine observations or specific measurements made repeatedly such as height & weight, ADLs

Flow Sheet or Graphic Records

18

reporting method using situation, background, assessment, and recommendation

SBAR reporting

19

the most common type of record where the patient chart is separated into sections that contain forms for each discipline

Source-Oriented Charting (SO)

20

science and art of turning data into information

Informatics

21

a nursing specialty that manages & communicates data, information, knowledge & wisdom by integrating nursing computer and information science

Nursing Informatics

22

A federal group formed in 2005 to advise the Secretary of the Department of Health and Human Services on methods of increasing EHR adoption in healthcare facilities.

American Health Information Community (AHIC)

23

a set of standards, services and policies that enable secure health information exchange (HIE) over the Internet.

National Health Information Network (NHIN)

24

an initiative that enables clinicians to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patient-centered, timely and equitable by interweaving evidence and technology seamlessly into practice, education and research fostering a learning healthcare system.

Technology Guiding Informatics Education Reform (TIGER)