Chapter 22

• Age, sex, marital status/significant other, religion, occupation, residence, next of kin, address, allergies, insurance status is include in what kind of form?

  Face sheet
• Admitting diagnosis; date of admission; current orders regarding diet, activity, frequency of vital signs measurement, daily weight, treatments, medications, diagnostic tests ordered, intravenous fluids, therapies ordered is included in what kind of form?

  Primary Care Provider's order
• Status during the past 24 hours is included in what kind of medical record review?

  Nurse's notes
• Findings from past 2 days’ status of problems is included in what kind of notes?

  Primary care provider’s progress notes
• Medications received, frequency of PRN medications, allergies are included in which kind of medical recors?

  MAR (Medication administration record) eMar (electronic medication administration record )
•  Current complaint, chronic problems, physical finding abnormalities, allergies, impressions is included in what kind of medical recording?

  Primary care provider’s patient history and physical examination
• Procedure done, organs removed, type of incision, drains or equipment in place, blood loss, problems during surgery is included in what kind of medical record?

  Surgery operative report
•  Presence of malignancy or infection is what kind of report?

  Pathology report
• Check for any abnormal findings: complete blood count, urinalysis, blood chemistries, x-ray films, culture and sensitivity, other tests is included in what kind of test?

  Current diagnostic tests
•  Reason for hospitalization, average number of cigarettes smoked per day, average amount of alcohol consumed per day, last bowel movement, special diet requirements, use of aids or prostheses (e.g., hearing aids or eyeglasses), medications taken regularly, identification of significant other, previous hospitalizations or surgeries, baseline vital signs, physical abnormalities is under what?

  Nursing admission history and assessment
• Risk factors to consider safety measures to provide is included in ?

  Fall Risk assessment
• Risk factors to consider areas needing inspection and care is what kind of assessment?

  Skin assessment
• • Breathing
  • How patient is feeling
  • Appearance
  • Affect
  • Skin color

  These are included in what kind of observation?

  Initial observation
• In which section of the chart would the nurse find the admitting diagnosis?

  Providers order
• In which section of the chart would the nurse find the patient’s insurance information?

  face sheet
• In which section of the chart would the nurse find an updated complete blood count?

  current diagnostic tests
• Which action by the nurse is appropriate when assessing an older adult who is having difficulty with memory?

  asking a family member