The document provides information about proper documentation practices in patient care. It discusses maintaining privacy of patient information, complying with HIPAA, documenting pain assessments, and the importance of documentation for patient care and treatment. Abbreviations used in documentation are also defined.
The document provides information about proper documentation practices in patient care. It discusses maintaining privacy of patient information, complying with HIPAA, documenting pain assessments, and the importance of documentation for patient care and treatment. Abbreviations used in documentation are also defined.
The document provides information about proper documentation practices in patient care. It discusses maintaining privacy of patient information, complying with HIPAA, documenting pain assessments, and the importance of documentation for patient care and treatment. Abbreviations used in documentation are also defined.
The document provides information about proper documentation practices in patient care. It discusses maintaining privacy of patient information, complying with HIPAA, documenting pain assessments, and the importance of documentation for patient care and treatment. Abbreviations used in documentation are also defined.
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Nama : Ogis Sepnata R
NIM : 005221003 Kelas : GR-4A
CHAPTER 13
1. Documentation is an essential component of patient care
2. Maintain privacy and confidentiality of patient information at all times. 3. Mandatory compliance with the privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was introduced in 2003 to help ensure that patient information is kept confidential and to give patients more control over their personal healthcare information and who has access to it. 4. Pain management requires documentation of assessment, intervention, response, and reassessment of pain 5. Documenting of pain management is essential for tracking patient care and for supporting therapeutic treatment.
Translate these questions below English based on expression that you learn earlier 1. What do you take to ease the pain ? (Histori of medication) 2. Where is The pain located? Does it radiate to other areas? (Location) 3. Does it come and Go or is it continuous (Timing) 4. Does the pain have any specific pattern (Quality or character of pain) 5. What other treatments do you use to relieve The pain? (History of medication) 6. Does it vary With The time of day? (Timing) 7. Is The pain new or have you had this pain before? If so, when? (Timing) 8. Is there a specific factor that tringgers The pain? (Severity) 9. What is it like?is it Sharp, dull, stabbing, aching? (Quality or character of pain) 10. Does anything make it better or worse? (Timing)
Complete the means of abbreviations below:
1. GU : genitourinary 2. NAD : no acute distress 3. Rt or: Radiotherapy 4. Sx : symptoms 5. Bx : biopsy 6. Cc : cubic centimeter; chief complaint 7. It or : Intermittent (physio) 8. do : Doctor of Osteopathic Medicine 9. GI : gastrointestinal 10. PMH : Pregnancy Medical Home 11. HPI : History of present illness 12. R/O : rule out 13. WNL : within normal limits
1. C&S : Culture and sensitivity 2. FBC: Full blood count 3. RBC : Red blood cells 4. WBC : White blood cells 5. CBC : Complete blood count 6. HPU : Has passed urine 7. lytes: Electrolytes 8. CVP : Central Venous Pressure
Complete the means of abbreviations below:
1. NPO : Nasal prong oxygen 2. CPR : Cardiopulmonary resuscitation 3. ROM : Range of motion; right otitis media; ruptured membranes 4. AMA : Against medical advice 5. HS : Hour of sleep; high school; nigh 6. DNR : Do not resuscitate 7. NS : Nurse screen 8. c : With 9. O.T. : Ophthalmic medical practitioner 10. TOP : Termination of pregnancy 11. Stat : At once 12. Ad lib : Freely 13. SWO : Standard Written Order
Cardiopulmonary Symptoms in Physical Therapy Practice -- Meryl Cohen, Theresa Hoskins Michel -- New York, New York State, 1988 -- Churchill -- 9780443085581 -- 7431a6ad6e7ecf7189aadea5ac4c154d -- Anna’s Archive
