![]() O-Objective-observable information (test results, BP readings)Ī-Assesment-patient's progress and evaluation of the plan's effectveness and any newfound problems or diagnosis is noted here _SOAP_ format or variation What info is only found in History and Physicial? Why they are here? Medications, symptoms, ONLY PLACE YOU WILL FIND SOCIAL HISTORY!!! Define SOAP. Includes _initial_ impressions or diagnosis of the patient's medical complaint Information about the patient's past and present medical history and physical examination findings ![]() the admission note What info is found in the History and Physical? Also called the _admission_ note Presented in a typed narrative, graphic, or diagrammatic format What section is found after Operation Room Procedures? History and Physical a.k.a. Invasive hemodynamic monitoring What section follows diagnostic procedures and consults? Operating Room Procedures What does the Operation Room Procedures section contain? Contain information of a patient's _operation_ Results may first be available on computer What types of test categories are there in Laboratory Data? HematologyĪrterial blood tests What section follows Laboratory Data? Diagnostic Procedures/Consults What is contained in diagnostic procedures and consults? Presented in standardized format Never make a decision just on one value such as WBC high from one test/day. Lab tests results in the chart typically appear in summary form and are updated daily Patient's most recent values will be reported in the computer review this source _first. Most facilities will have a _computer_ -based lab system _Discharge_ planning What section of the chart follows nursing notes? Laboratory Data What information can be found in Laboratory Data? Lab test results are usually contained in one section What information can be found in nursing notes? Physical functioning (are they moving)ĪNY AS NEEDED MEDICATIONS THAT WERE GIVEN!!!! Nursing Notes can be separate or will be part of the progress notes. What are nursing notes exactly? Used to document _observations_ and patient care _activities_Ĭan be separate section or integrated in physician's progress notes Neurologic checks What is the section of the patient's chart after graphic charts? Nursing notes. Quantitative records of _repetitive monitoring activitiesĪrranged to easily visualize _trends_ and _patternsĬan be standardized to specific nursing units or patients receiving special therapy Name examples what information can be obtained from graphic charts. Standardized forms that simplify data collection and retrieval ![]() What are graphic charts also known as and what information do the contain? Also known as _flowsheets_ Telephone What follows physician orders? Graphic Charts. What comes after Admitting data? Physician Orders What are physician orders and what types are there? _Directives_ for patient treatment Health Insurance Portability and Accountability Act (HIPAA) formsĪll types of FORMS are going to be in admitting data. Besides information, what else must be filed under admitting data? Consent Formsĭocuments risks and benefits of a specific action that takes place during admission
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