Pharm Care: Introduction to the Patient Chart
Terms
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- Definition: A mechanism for communication among healthcare professionals and it is a legal document of the patients health status
- Patient Chart
- Defintion: A system used to bring attention to key things within a patient chart
- A "flag system"
- How many medical charts are there per patient?
- One
- What is the first section of the patient medical chart?
- Admitting Data
- How many sections are in the Admitting Data?
- Four
- What are the four sections of the Admitting data?
-
Biographical Data
Financial/Insurance Data
Admissions-related Data
Consent forms - Which section of the patient chart contains Biographical Data?
- Admitting Data
- Which section of the patient chart contains Financial/Insurance Data?
- Admitting Note
- Which section of the patient chart contains Admissions-related Data?
- Admitting Data
- Which section of the patient chart contains Consent Forms?
- Admitting Data
- Definition: Directives for patient treatment written either by a physician or by another health professional and countersigned by a physician
- Physician Orders
- What is another term for physician orders?
- Transcription
- Quantitative records of repetitive monitoring activities (arranged so patterns are easy to visualize)
- Graphic Charts
- Which section of the patient chart contains vital signs?
- Graphic Charts
- Which section of the patient chart contains blood glucose values?
- Graphical Charts
- Which section of the patient chart contains I&O data?
- Graphic Charts
- Which section of the patient chart contains IV fluid rates?
- Graphic Charts
- What type of information is displayed using graphic charts? (4)
-
vital signs
I&O data
blood glucose values
IV fluid rates - Definition: A detailed summary of the patient's entire hospital course (from the nurses point of view)
- Nursing Notes
- Which section of the patient chart contains clinical signs and symptoms?
- Nursing Notes
- Which section of the patient chart contains nursing interventions?
- Nursing Notes
- Which section of the patient chart contains documentation of care?
- Nursing notes
- Which section of the patient chart contains nursing care plans?
- Nursing Notes
- Which section of the patient chart contains discharge care plans?
- Nursing notes
- Which section of the patient chart contains serum chemistries?
- Laboratory Values
- Which section of the patient chart contains lab test results?
- Laboratory Values
- Which section of the patient chart contains the results of diagnostic tests?
- Diagnostic Procedures/Consults/OR Procedures
- What is another name for History and Physical?
- Admitting note
- What is the largest section of the patient charge?
- History and Physical (Admitting note)
- Where does the physician usually write his or her initial findings and impressions?
- History and Physical (Admitting Note)
- How many componets are there in the admitting note?
- Six
-
What are the six componets of the admitting note?
(History & Physical) -
Patient Identification
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Assessment
Plan - Which section of the patient chart contains patient identification?
- History and Physical (admitting note)
- Which section of the patient chart contains the chief complaint?
- History and Physical (admitting note)
- Which section of the patient chart contains history of present illness?
- History and Physical (admitting note)
- Which section of the patient chart contains past medical history?
- History and Physical (admitting note)
- Which section of the patient chart contains the assessment?
- History and Physical (admitting note)
- Which section of the patient chart contains the plan?
- History and Physical (Admitting note)
- Definition: The immediate problem that brought the patient to the hospital or the reason the patient was admitted.
- Chief Complaint
- CC
- Chief Complaint
- HPI
- History of Present Illness
- PMH
- Past Medical History
- FHx
- Family History
- SHx
- Social History
- Definition: Clear sequence of events that led the patient to seek medical attention.
- History of Present Illness
- Definition: Describes the patients more remote medical problems or illnesses that may or may not be related to the admitting note.
- Past Medical History
- What are the 5 componets of Past Medical History?
-
Medication History
Family History
Occupation
Diet
Social History - Which section of the patient chart contains medication history?
- Past Medical History
- Which section of the patient chart contains family history?
- Past Medical History
- Which section of the patient chart contains occupation?
- Past Medical History
- Which section of the patient chart contains diet?
- Past Medical History
- Which section of the patient chart contains social history?
- Past Medical History
- What is found in Social History?
-
-marital status, sexual preference
-tobacco, alcohol use, illicit drugs
-hobbies - What FOUR factors must be included in the Medication History?
-
Drug name
Dose
Regimen
Duration - ROS
- Review of Systems
- PE
- Physical Exam
- MAR
- MEDICATION Administration Record
- Definition: A listing of all medications that the patient recieved while they were in the hospital.
- MEDICATION Administration Record
- POMR
- Patient-Oriented Medical Record
- What is the format of the Patient-Oriented Medical Record?
-
1. Patient Data Base
2. The Problem List
3. Progress Notes - Which section of the Patient-Oriented Medical Record contains patient identification?
- Patient Data Base
- Which section of the Patient-Oriented Medical Record contains the chief complaint?
- Patient Data Base
- Which section of the Patient-Oriented Medical Record contains History of present illness?
- Patient Data Base
- Which section of the Patient-Oriented Medical Record contains past medical history?
- Patient Data Base
- Which section of the Patient-Oriented Medical Record contains Review of Systems/Physical Exam?
- Patient Data Base
- Definition: A running commentary on the patient's condition and treatments (including response to treatment from admission to discharge).
- Progress Notes
- Who does the patient medical CHART belong to?
- The hospital
- Who does the INFORMATION contained in a patient medical chart belong to?
- The patient
- Definition: A legal document of the health services provided to the patient during hospitalization.
- Patient medical chart