list in order the 10 rules for transcribing doctors orders - Answers 1- read the complete set of doctors
orders
2- order medications from the pharmacy department
3- complete all stat orders
4- place telephone calls as necessary
5- select the patients identifying information and collect all necessary forms
6- order diagnostic tests, treatment and supplies
7- kardex all the doctors orders except medication orders
8- complete medication orders by writing them on the MAR
9- recheck each step for accuracy and thoroughness
10- sign off the completed set of the doctors orders
what is the difference between an invasive and a non invasive procedure - Answers invasive - a
diagnostic/therapeutic technique that requires an incision or entry of a body cavity or organ, requires a
signed consent form
non invasive - a diagnostic/therapeutic technique that does not require that the skin be broken or a
cavity or organ of the body to be entered, doesn't require patient to sign a consent form
list 3 things to include when ordering oxygen - Answers 1- amount of oxygen
2- flow rate and concentration
3- type of delivery device (nasal prongs, mask)
list and define two different types of dialysis - Answers hemodialysis- the removal of waste products
from the blood through use of a machine through which the blood flows
peritoneal dialysis- filling the abdominal cavity with dialysis filtrate and allowing osmosis to filter the
blood over 4-8 hours
explain in detail the process of chart thinning - Answers 1- remove older nurses notes, medication
forms, and other forms that are no longer needed
, 2- place the removed forms in an envelope
3- place the patients ID label on the outside of the envelope
4- write "thinned chart" and record the date with your first initial and last name on the outside of the
envelope
5-place a label on the front of the patients chart stating that the chart was thinned, along with the date
and the first initial and last name of the person thinning the chart
6- if the patient is transferred to another unit, transfer the thinned out forms with the patients chart
7- when the patients is discharged, send all thinned out forms with the patients paper chard to the
health information management department
name 5 guidelines for writing on a patients chart - Answers - all entries must be made in ink
- the written entries must be legible and accurate
- recorded entries on the chart may not be obliterated or erased
-all entries must include the date and time the entry is made
-only approved abbreviations may be used
name 5 components of a medication order - Answers 1- name
2- dose
3- route
4- frequency
5- qualifying phrase
define crackles - Answers a common, abnormal respiratory sound that consist of discontinuous bubbling
noises caused by fluid in the small airways and heard on auscultation of the chest during inspiration
define stidor - Answers a high pitched harsh sound heard during inspiration that is caused by obstruction
of the upper airway sign of respiratory distress - requires immediate attention
define CABG - Answers coronary artery bypass graft
define standing orders - Answers a doctors order that remains in effect and is executed as ordered until
the doctor discontinues or changes it
define one time orders - Answers a doctors order that is executed according to the qualifying phrase,
and then is automatically discontinued