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

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 Normal ranges for the average healthy adult vital signs - Blood Pressure normal BP is less than 120 (Diastolic) and less than 80 (systolic) Breathing 12 - 18 breaths per minute Pulse 60 - 80 beats per minute (at rest) Temperature 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit Febrile presence of fever Afebrile absence of fever Fever elevated body temperature beyond normal range Intermittent fluctuating fever that returns to or below baseline then rises again Remittent fluctuating fever that remains elevated; it does not return to baseline temperature. Continuous a fever that remains constant above the baseline; it does not fluctuate Pyrexia when a patient has an oral temperature of 100.8°F Hyperpyrexia when a patient presents with an oral temperature of 104°F or higher Pulse The normal adult pulse rate ranges between 60 and 100 beats per minute Respiration The normal range for adults is 12 to 20 per minute Some rate abnormalities may be: Apnea his is a temporary complete absence of breathing which may be a result of a reduction in the stimuli to the respiratory centers of the brain. Tachypnea this is a respiration rate of greater than 40/min. It is transient in the newborn and maybe caused by the hysteria in the adult. Bradypnea decrease in numbers of respirations. This occurs during sleep. It may also be due to certain diseases. 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 Normal ranges for the average healthy adult vital signs - Blood Pressure normal BP is less than 120 (Diastolic) and less than 80 (systolic) Breathing 12 - 18 breaths per minute Pulse 60 - 80 beats per minute (at rest) Temperature 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit Febrile presence of fever Afebrile absence of fever Fever elevated body temperature beyond normal range Intermittent fluctuating fever that returns to or below baseline then rises again Remittent fluctuating fever that remains elevated; it does not return to baseline temperature. Continuous a fever that remains constant above the baseline; it does not fluctuate Pyrexia when a patient has an oral temperature of 100.8°F Hyperpyrexia when a patient presents with an oral temperature of 104°F or higher Pulse The normal adult pulse rate ranges between 60 and 100 beats per minute Respiration The normal range for adults is 12 to 20 per minute Some rate abnormalities may be: Apnea his is a temporary complete absence of breathing which may be a result of a reduction in the stimuli to the respiratory centers of the brain. Tachypnea this is a respiration rate of greater than 40/min. It is transient in the newborn and maybe caused by the hysteria in the adult. Bradypnea decrease in numbers of respirations. This occurs during sleep. It may also be due to certain diseases.