NURS 522 Advanced Health Assessment
Exam 1
Describe how to make a correction in a paper medical record. - ANS -When making a correction
in a paper record, you should draw a single line through the text that is erroneous, initial and
date the entry, and label it as an error. If there is room, you may enter the correct text in the
same area of the note. You should not write in the margins of a page; if there is no room to enter
the correct text, use an addendum to record the information. You should never obliterate an
original note, nor should you use correction fluid or tape.
\Discuss the purpose of and components of the New Ballard score. - ANS -The New Ballard
Score is a set of procedures developed by Dr. Jeanne L Ballard, MD to determine Gestational
Age through neuromuscular and physical assessment of a newborn infant. It provides detailed
information on gestational age assessment, specifically focused on the New Ballard Score.
Monograph: Performing the Assessment of Neuromuscular Maturity
a) Posture
Total body muscle tone is reflected in the infant's preferred posture at rest and resistance to
stretch of individual muscle groups. As maturation progresses, the fetus gradually assumes
increasing passive flexor tone that proceeds in a centripetal direction, with lower extremities
slightly ahead of upper extremities. For example, very early in gestation only the ankles are
flexed. Knees will flex as wrists just begin to flex. Hip flexion, then adduction are just ahead of
elbow, then shoulder girdle flexion. The preterm infant primarily exhibits unopposed passive
extensor tone, while the infant approaching term shows progressively less opposed passive
flexor tone.
b) Square Window
Wrist flexibility and/or resistance to extensor stretching are responsible for the resulting angle of
flexion at the wrist. The examiner straightens the infant's fingers and applies gentle pressure on
the dorsum of the hand, close to the fingers. From extremely pre-term to post-term, the resulting
angle between the palm of the infant's hand and forearm is estimated at; >90°, 90°, 60°, 45°,
30°, and 0°. The appropriate square on the score sheet is selected.
c) Arm Recoil
This maneuver focuses on passive flexor tone of the biceps muscle by measuring the angle of
recoil following very brief extension of the upper extremity. With the infant lying supine, the
examiner places one hand beneath the infant's elbow for support. Taking the infant's hand, the
examiner briefly sets the elbow i
\During the skin examination, what is the ABCDE-EFG rule? - ANS -- Asymmetry of one side of
mole compared to the other.
- Border irregularity, especially if ragged, notched, or blurred.
,- Color variations, more than two colors, especially blue-black, white (loss of pigment due to
regression), or red (inflammatory reaction to abnormal cells).
- Diameter >6 mm, approximately the size of a pencil eraser.
- Evolving, or changing rapidly in size, symptoms, or morphology.
● Elevated
● Firm to palpation
● Growing progressively over several weeks.
\For Admission Orders, what does ADCAVADIMPLS stand for? - ANS -AD CAVA DIMPLS
- Admit: admitting physician and type of unit or hospital floor
- Diagnosis: chief reason for the patient's admission
- Condition: usually a one-word description
- Activity: level of activity allowed depending on age, diagnosis, medications, etc.
- Vital signs: frequency with which vital signs should be obtained
- Allergies: list any medication allergies - Diet: what type of diet the patient is allowed
- Interventions: IV therapy, respiratory therapy, etc.
- Medications: medications related to reason for admission and any chronic medications the
patient may be taking
- Procedures: wound care, ostomy care, etc.
- Labs: any laboratory or diagnostic tests needed
- Special instructions: notify if certain parameters are exceeded, or conditional orders (if this
occurs, do this).
\For the Post-Operative Note, what does SAPPPA HEMI stand for? - ANS -Surgeon
Assistant/s
Pre-Operative Diagnosis
Post-Operative Diagnosis
Procedure
Anesthesia
Hemostasis
Estimated Blood Loss (EBL)
Materials
Injectables
\How does culture influence the patient interview? - ANS -Culture shapes not just the patient's
beliefs, but your own. Culture is a system of shared ideas, rules, and meanings that influences
how we view the world, experience it emotionally, and behave in relation to other people.
\ICD codes are used to identify what? - ANS -Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
\Identify at least five potential barriers to implementing an EMR system. - ANS -Limited
computer literacy on the part of providers
b) Concerns over security, productivity, patient satisfaction, and unreliable technology
c) Costs of hardware and software
d) Concerns about safety and security of systems and the ability to protect and keep private
confidential health information
, e) Technical matters, such as functionality, ease of use, and customer support from vendors are
other barriers
\Identify at least two conditions that are considered sensitive PHI. - ANS -a) HIV
b) Substance abuse
\Identify five perceived benefits of an EMR system. - ANS -An electronic system would provide
immediate access to key information, such as diagnoses, allergies, laboratory test results, and
medications, that would improve the provider's ability to make sound clinical decisions in a
timely manner.
b) Result management would ensure that all providers participating in the care of a patient
would have quick access to new and past test results, regardless of who ordered the tests, the
geographic location of the ordering provider, or when the tests were ordered or performed.
c) Order management would include the ability to enter and store orders for prescriptions, tests,
and other services in a computer-based system that would enhance legibility, reduce
duplication, reduce fragmentation, and improve the speed with which orders are executed.
d) Using reminders, prompts, and alerts, computerized decision-support systems would improve
compliance with best clinical practices, ensure regular screenings and other preventive
practices, identify possible drug-drug or drug-disease interactions, and facilitate diagnoses and
treatments.
e) Patients would be provided tools that give them access to their health records and interactive
patient education and that would help them carry out home-monitoring and self-testing to
improve control of chronic conditions.
\Identify objective information that should be documented in a postpartum note. - ANS
-Objective findings that you should document include general assessment, vital signs, breast
examination, uterine tone, fundal height, and amount and character of lochia. If postoperative,
document the appearance of the surgical incision; if the patient had an episiotomy, document
the appearance of the perineum and include important laboratory data such as hemoglobin,
even if normal, and any abnormal values from the CBC.
\Identify subjective information that should be documented in a postpartum note. - ANS
-Subjective information that you should document includes any complaints the patient may
have, ability to ambulate, pain control, whether patient is breastfeeding or bottle feeding, and
ability to void. If postoperative, ask the patient about presence or absence of flatus.
\In ADCAVADIMPLS, what are the possible Activity orders? - ANS -• Up ad lib (the patient may
be out of bed as he or she wishes)
• Activity as tolerated (whatever the condition allows the patient to do)
• Bedrest with bathroom privileges, abbreviated as BR with BRP (allowed out of bed to go to the
bathroom; otherwise in bed)
• Out of bed (OOB)
• Ambulate a certain number of times a day
• Ambulate with assistance
• Non-weight-bearing
\In addition to other health-care providers, list five different types or groups of people who could
read medical records you create. - ANS -a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
Exam 1
Describe how to make a correction in a paper medical record. - ANS -When making a correction
in a paper record, you should draw a single line through the text that is erroneous, initial and
date the entry, and label it as an error. If there is room, you may enter the correct text in the
same area of the note. You should not write in the margins of a page; if there is no room to enter
the correct text, use an addendum to record the information. You should never obliterate an
original note, nor should you use correction fluid or tape.
\Discuss the purpose of and components of the New Ballard score. - ANS -The New Ballard
Score is a set of procedures developed by Dr. Jeanne L Ballard, MD to determine Gestational
Age through neuromuscular and physical assessment of a newborn infant. It provides detailed
information on gestational age assessment, specifically focused on the New Ballard Score.
Monograph: Performing the Assessment of Neuromuscular Maturity
a) Posture
Total body muscle tone is reflected in the infant's preferred posture at rest and resistance to
stretch of individual muscle groups. As maturation progresses, the fetus gradually assumes
increasing passive flexor tone that proceeds in a centripetal direction, with lower extremities
slightly ahead of upper extremities. For example, very early in gestation only the ankles are
flexed. Knees will flex as wrists just begin to flex. Hip flexion, then adduction are just ahead of
elbow, then shoulder girdle flexion. The preterm infant primarily exhibits unopposed passive
extensor tone, while the infant approaching term shows progressively less opposed passive
flexor tone.
b) Square Window
Wrist flexibility and/or resistance to extensor stretching are responsible for the resulting angle of
flexion at the wrist. The examiner straightens the infant's fingers and applies gentle pressure on
the dorsum of the hand, close to the fingers. From extremely pre-term to post-term, the resulting
angle between the palm of the infant's hand and forearm is estimated at; >90°, 90°, 60°, 45°,
30°, and 0°. The appropriate square on the score sheet is selected.
c) Arm Recoil
This maneuver focuses on passive flexor tone of the biceps muscle by measuring the angle of
recoil following very brief extension of the upper extremity. With the infant lying supine, the
examiner places one hand beneath the infant's elbow for support. Taking the infant's hand, the
examiner briefly sets the elbow i
\During the skin examination, what is the ABCDE-EFG rule? - ANS -- Asymmetry of one side of
mole compared to the other.
- Border irregularity, especially if ragged, notched, or blurred.
,- Color variations, more than two colors, especially blue-black, white (loss of pigment due to
regression), or red (inflammatory reaction to abnormal cells).
- Diameter >6 mm, approximately the size of a pencil eraser.
- Evolving, or changing rapidly in size, symptoms, or morphology.
● Elevated
● Firm to palpation
● Growing progressively over several weeks.
\For Admission Orders, what does ADCAVADIMPLS stand for? - ANS -AD CAVA DIMPLS
- Admit: admitting physician and type of unit or hospital floor
- Diagnosis: chief reason for the patient's admission
- Condition: usually a one-word description
- Activity: level of activity allowed depending on age, diagnosis, medications, etc.
- Vital signs: frequency with which vital signs should be obtained
- Allergies: list any medication allergies - Diet: what type of diet the patient is allowed
- Interventions: IV therapy, respiratory therapy, etc.
- Medications: medications related to reason for admission and any chronic medications the
patient may be taking
- Procedures: wound care, ostomy care, etc.
- Labs: any laboratory or diagnostic tests needed
- Special instructions: notify if certain parameters are exceeded, or conditional orders (if this
occurs, do this).
\For the Post-Operative Note, what does SAPPPA HEMI stand for? - ANS -Surgeon
Assistant/s
Pre-Operative Diagnosis
Post-Operative Diagnosis
Procedure
Anesthesia
Hemostasis
Estimated Blood Loss (EBL)
Materials
Injectables
\How does culture influence the patient interview? - ANS -Culture shapes not just the patient's
beliefs, but your own. Culture is a system of shared ideas, rules, and meanings that influences
how we view the world, experience it emotionally, and behave in relation to other people.
\ICD codes are used to identify what? - ANS -Physical exam findings, Reason for office visit,
Complaints, Diagnosis, Symptoms, Conditions
\Identify at least five potential barriers to implementing an EMR system. - ANS -Limited
computer literacy on the part of providers
b) Concerns over security, productivity, patient satisfaction, and unreliable technology
c) Costs of hardware and software
d) Concerns about safety and security of systems and the ability to protect and keep private
confidential health information
, e) Technical matters, such as functionality, ease of use, and customer support from vendors are
other barriers
\Identify at least two conditions that are considered sensitive PHI. - ANS -a) HIV
b) Substance abuse
\Identify five perceived benefits of an EMR system. - ANS -An electronic system would provide
immediate access to key information, such as diagnoses, allergies, laboratory test results, and
medications, that would improve the provider's ability to make sound clinical decisions in a
timely manner.
b) Result management would ensure that all providers participating in the care of a patient
would have quick access to new and past test results, regardless of who ordered the tests, the
geographic location of the ordering provider, or when the tests were ordered or performed.
c) Order management would include the ability to enter and store orders for prescriptions, tests,
and other services in a computer-based system that would enhance legibility, reduce
duplication, reduce fragmentation, and improve the speed with which orders are executed.
d) Using reminders, prompts, and alerts, computerized decision-support systems would improve
compliance with best clinical practices, ensure regular screenings and other preventive
practices, identify possible drug-drug or drug-disease interactions, and facilitate diagnoses and
treatments.
e) Patients would be provided tools that give them access to their health records and interactive
patient education and that would help them carry out home-monitoring and self-testing to
improve control of chronic conditions.
\Identify objective information that should be documented in a postpartum note. - ANS
-Objective findings that you should document include general assessment, vital signs, breast
examination, uterine tone, fundal height, and amount and character of lochia. If postoperative,
document the appearance of the surgical incision; if the patient had an episiotomy, document
the appearance of the perineum and include important laboratory data such as hemoglobin,
even if normal, and any abnormal values from the CBC.
\Identify subjective information that should be documented in a postpartum note. - ANS
-Subjective information that you should document includes any complaints the patient may
have, ability to ambulate, pain control, whether patient is breastfeeding or bottle feeding, and
ability to void. If postoperative, ask the patient about presence or absence of flatus.
\In ADCAVADIMPLS, what are the possible Activity orders? - ANS -• Up ad lib (the patient may
be out of bed as he or she wishes)
• Activity as tolerated (whatever the condition allows the patient to do)
• Bedrest with bathroom privileges, abbreviated as BR with BRP (allowed out of bed to go to the
bathroom; otherwise in bed)
• Out of bed (OOB)
• Ambulate a certain number of times a day
• Ambulate with assistance
• Non-weight-bearing
\In addition to other health-care providers, list five different types or groups of people who could
read medical records you create. - ANS -a. Attorneys
b. Malpractice carriers
c. Jurors/Judges
