objective data
Give this one a try later!
, -what the provider observes
-what is seen, felt, heard, smelled, NOT the pt's POV
-vital signs, including weight, height, BMI
-physical examination (depends on pt complaint)
-pediatrics: requires patience and distraction, sitting in parent's lap can be
helpful, examine the area most upsetting last
limiting differentials
Give this one a try later!
-after you organize the differentials, work through the history and exam,
eliminate possibilities to narrow the list
-each pt is individual, making some diseases irrelevant as a possibility (ex.
appendicitis in a pt who had an appendectomy)
pediatric exam documentation
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-Skin, lymph nodes, lung sounds, heart rate and rhythm, abdomen, GU,
musculoskeletal, neuro (reflexes): all ages
-Umbilical cord: birth until healed
-Palate: most critical in infancy
-Eyes red reflex: birth until infancy
-Head: birth until fontanels close
Health Care in the U.S.
Give this one a try later!
, -rapid changes
-aging population
-increased chronic care management
-increased complexity
-shortage of primary care providers
nursing
Give this one a try later!
"The most critical contribution of nursing to patient safety, in any setting, is
the ability to coordinate and integrate multiple aspects of quality within the
care directly provided by nursing, and across the care delivered by others
in the setting."
safeguards for prescribers
Give this one a try later!
-safe storage
-write out actual amount
-never sign blank forms in advance
-work with pharmacists
-use tamper-resistant prescription pads
-do not include DEA on pre printed forms
-do not display DEA certificate
-limit access to DEA number
plan
Give this one a try later!
, -what the provider observes
-what is seen, felt, heard, smelled, NOT the pt's POV
-vital signs, including weight, height, BMI
-physical examination (depends on pt complaint)
-pediatrics: requires patience and distraction, sitting in parent's lap can be
helpful, examine the area most upsetting last
limiting differentials
Give this one a try later!
-after you organize the differentials, work through the history and exam,
eliminate possibilities to narrow the list
-each pt is individual, making some diseases irrelevant as a possibility (ex.
appendicitis in a pt who had an appendectomy)
pediatric exam documentation
Give this one a try later!
-Skin, lymph nodes, lung sounds, heart rate and rhythm, abdomen, GU,
musculoskeletal, neuro (reflexes): all ages
-Umbilical cord: birth until healed
-Palate: most critical in infancy
-Eyes red reflex: birth until infancy
-Head: birth until fontanels close
Health Care in the U.S.
Give this one a try later!
, -rapid changes
-aging population
-increased chronic care management
-increased complexity
-shortage of primary care providers
nursing
Give this one a try later!
"The most critical contribution of nursing to patient safety, in any setting, is
the ability to coordinate and integrate multiple aspects of quality within the
care directly provided by nursing, and across the care delivered by others
in the setting."
safeguards for prescribers
Give this one a try later!
-safe storage
-write out actual amount
-never sign blank forms in advance
-work with pharmacists
-use tamper-resistant prescription pads
-do not include DEA on pre printed forms
-do not display DEA certificate
-limit access to DEA number
plan
