TPR Graph Purpose: Understanding Client's Chart in Healthcare

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Questions and Answers

What is the primary purpose of admitting a patient for observational stay?

To monitor vital signs and detect any potential complications (correct)
To provide medical care for a stable patient
To conduct surgical treatments
To perform elective procedures

What is the main difference between elective and emergency admissions?

The timing and preparation of the admission (correct)
The type of treatment provided to the patient
The level of care required by the patient
The duration of the patient's stay

What is the primary responsibility of the admitting department?

Entering and accepting patients into the healthcare facility (correct)
Conducting medical investigations
Monitoring patient vital signs
Providing medical treatment

What is the purpose of an address or graph card in the admission process?

To identify the patient's address and contact information (A) Signup and view all the answers

What is the main reason for admitting a patient for a diagnostic investigation?

To determine the underlying cause of a patient's symptoms (C) Signup and view all the answers

What is the purpose of a consent form in the admission process?

To obtain patient consent for treatment (B) Signup and view all the answers

What is the primary purpose of a client's chart in healthcare?

To facilitate communication between different healthcare professionals (C) Signup and view all the answers

What is the main function of a nurse's admission assessment?

To provide a summary of nursing history and physical assessment (C) Signup and view all the answers

What is the purpose of a physician's order sheet?

To serve as a record of physician's orders for treatment and medications (C) Signup and view all the answers

What is the main function of a graphic sheet and flow sheet in a patient's chart?

To record repeated observations and measurements, such as vital signs and intake/output (A) Signup and view all the answers

What is the purpose of a discharge summary in a patient's chart?

To summarize the patient's condition, progress, and rehabilitation needs at time of discharge (C) Signup and view all the answers

What is the primary purpose of a TPR sheet in a patient's chart?

To show patient clinical information for physicians to judge patient condition (C) Signup and view all the answers

What is the primary goal of identifying a patient during the admission process?

To confirm the patient's identity (D) Signup and view all the answers

What type of medication order is given on an 'as needed' basis for specific signs and symptoms?

PRN Medication Orders (D) Signup and view all the answers

What is the term for the movement of a patient within the same healthcare facility?

Transfer (D) Signup and view all the answers

What is the purpose of the Seven Important Questions before administering medication?

To ensure the correct medication is administered (D) Signup and view all the answers

Which of the following is NOT a type of nursing responsibility during admission?

Provide medication (C) Signup and view all the answers

What is a concern for newly admitted patients?

Decreased privacy (B) Signup and view all the answers

What is the primary purpose of a Kardex form?

To provide a quick reference to a client's current orders (A) Signup and view all the answers

What is Kardexing?

The process of recording and updating doctor's orders on the Kardex form (A) Signup and view all the answers

What is the primary goal of accurate documentation in charting?

To provide a clear picture of the client's situation (B) Signup and view all the answers

What is the purpose of a Kardex file?

To organize and store Kardex forms for each patient in the nursing unit (D) Signup and view all the answers

What is included in the basic demographic data on a Kardex form?

Basic information such as name, room number, age, and admission date (A) Signup and view all the answers

What is the significance of matching the medication log entry and the order?

To prevent medication errors and ensure accuracy (D) Signup and view all the answers

What is the definition of pulse pressure?

The difference between the systolic and diastolic pressure (B) Signup and view all the answers

Which type of sphygmomanometer eliminates the need to listen to the sounds of the client's systolic and diastolic blood pressures through a stethoscope?

Electronic sphygmomanometer (C) Signup and view all the answers

What is the term for the act of bringing oxygen into the body and removing carbon dioxide?

Respiration (A) Signup and view all the answers

What is the term for the fluids that enter the client's body?

Intake (D) Signup and view all the answers

Which pulse site is located in the neck?

Carotid pulse (C) Signup and view all the answers

What is the device used to measure blood pressure?

Sphygmomanometer (A) Signup and view all the answers

Study Notes

Medication Administration

Medication log entry, order, and prescription label must match
Documentation is also known as record keeping
Kardex is a form or card used to record doctor's orders and organize information for quick reference

Kardex

Kardex form is used by nursing staff to record doctor's orders
Kardex file is a portable file that contains and organizes kardex forms for each patient in the nursing unit
Kardexing is the process of recording and updating doctor's orders on the kardex form
Kardex contents include basic demographic data, list of medications, intravenous fluids, daily treatments, diagnostic procedures, allergies, and specific data

Charting

Charting is the process of entering information in the patient's record
Types of charting include narrative, observational, and outpatient stay
General principles of charting include accuracy, with documented observations giving an appropriate picture of the client's situation

Admission

Admission is the entry and acceptance of a patient to stay in a health facility for observation, investigation, and treatment
Types of admissions include inpatient stay (longer than 24 hours) and outpatient stay (less than 24 hours)
Inpatient stay can be elective/planned, routine, or emergency
Responsibilities of the admitting department include preparing for admission, completing medical records, and obtaining consent forms

Client's Chart

Client's chart is a formal, legal document that provides evidence of a client's care
Purposes of a client's chart include communication, planning client care, and auditing health agencies
Components of a client's chart include physician's order sheet, nurse's admission assessment, graphic sheet, medical history, and physician's progress notes

Vital Signs

Pulse pressure is the difference between the diastolic and systolic pressure
Pulse sites include temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, and pedal (dorsalis pedis)
Respiration is the act of bringing oxygen into the body and removing carbon dioxide
Blood pressure is the force of blood against the arterial walls in the body, measured using a sphygmomanometer
Types of sphygmomanometers include aneroid, mercury, and electronic
Intake refers to all fluids entering the client's body, while output refers to all fluids that leave the client's body

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Description

Test your knowledge of the client's chart, a formal document that records a patient's clinical data and medical history. Learn about the purposes of the client's chart, including communication and planning client care.

Client's Chart in Healthcare

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