N202 Guidelines for recording the database

  1. What are significant "positives"?
    Signs and symptoms that are present; they are recorded first
  2. What are significant negatives?
    Signs and symptoms not present; recorded after significant positives
  3. Format for recording the database?
    • a) use headlines to delineate topics
    • b) record subjective information in narrative style
    • c) use short phrases
    • d) use quotes only when helpful conveying message
    • e) use appropriate medical terminology
    • f) data should be measureable quantifiable
    • g) avoid vague terms ie "good" "normal"
  4. How to note an error in documentation
    put a line through data and initial it
  5. Medical record is considered a......
    legal document ( if it wasnt written down it was not done)
  6. Physical examination order for the body besides the abdomen
    • a) inspection
    • b)palpation
    • c) percussion
    • d)auscultation
  7. Physical examination order for the abdomen
    • a) inspection
    • b) ausculation
    • c)percussion
    • d) palpation
  8. Always include presence or absence of constitutional symptoms when appropriate. Examples....
    • fever, chills, sweats (f/v/s)
    • nausea, vomiting, diarrhea (n/v/d)
    • weight loss
  9. Reason for use of scales
    • Helps quantify measures (include the limits)
    • ie. pain (4/10) 0= no pain/ 10=severe pain)
  10. When are diagrams appropriate?
    When they clarify and simplify descriptions and findings
Card Set
N202 Guidelines for recording the database
SDSU N202 Guidelines for recording the database