RNSG 1413: First Test – Questions With Accurate
Solutions
Groups
Play your way to mastery with fun games
Match Blocks Charms NEW
Practice questions for this set
Learn 1/7 Study with Learn
low body temperature
Choose an answer
1 Hyperglycemia 2 Hypoxemia
3 Hyperthermia 4 Hypothermia
Don't know?
, Terms in this set (139)
Health Care Documentation any written or electronically generated information
about a patient that describes the patient, the patient's
health, and the care and services provided, including
the dates of care.
medical record a document with comprehensive information about a
patient's health care encounter, as well as demographic,
administrative, and clinical data
Electronic Medical Record (EMR) the documentation of a single episode of care
Computerized provider order entry allows clinicians to enter orders in a computer that are
(CPOE) sent directly to the appropriate department
Five steps of the nursing process 1) Assessment
2) Diagnosis
3) planning
4) Implementation
5) Evaluation
problem oriented medical record A system developed to organize a medical record that
(POMR) uses a common list of patient problems as its base
Charting by exception (CBE) documentation that records only abnormal or significant
data
medication administered record (MAR) a list of ordered medications, along with dosages,
routes, and times of administration, on which the nurse
initials medications given or not given
Solutions
Groups
Play your way to mastery with fun games
Match Blocks Charms NEW
Practice questions for this set
Learn 1/7 Study with Learn
low body temperature
Choose an answer
1 Hyperglycemia 2 Hypoxemia
3 Hyperthermia 4 Hypothermia
Don't know?
, Terms in this set (139)
Health Care Documentation any written or electronically generated information
about a patient that describes the patient, the patient's
health, and the care and services provided, including
the dates of care.
medical record a document with comprehensive information about a
patient's health care encounter, as well as demographic,
administrative, and clinical data
Electronic Medical Record (EMR) the documentation of a single episode of care
Computerized provider order entry allows clinicians to enter orders in a computer that are
(CPOE) sent directly to the appropriate department
Five steps of the nursing process 1) Assessment
2) Diagnosis
3) planning
4) Implementation
5) Evaluation
problem oriented medical record A system developed to organize a medical record that
(POMR) uses a common list of patient problems as its base
Charting by exception (CBE) documentation that records only abnormal or significant
data
medication administered record (MAR) a list of ordered medications, along with dosages,
routes, and times of administration, on which the nurse
initials medications given or not given
