Solutions11
Guidelines for appropriate documentation - ANSWERS-Clear, concise, complete, and accurate
Guidelines for legal documentation - ANSWERS--do not erase / use correction fluid
-do not document critical comments about pt or other HCP
-correct errors promptly
-record facts
-record legibly, black ink
-written entries should include, date & time
effective shift change report include : - ANSWERS--new problems or concerns
-contact with HCP & any new orders
-progress or current / established problems
-PRN meds
-briefly describe behavior
-Pt's ADL function
-whatever follow ups are still needed
-highlight and update key pt goals
medical record (the chart) - ANSWERS-legal record used to meet the demands of health,
accreditation, medical insurance and legal systems
normal range for BP - ANSWERS-120/80; high BP - hypertensive; low BP - hypotensive
, normal range for SP02 - ANSWERS-95-100%
normal temperature - ANSWERS-98.6 degrees F
37 degrees C
normal range for RR - ANSWERS-12-20
active range of motion - ANSWERS-Range of motion exercises completed by the resident
without assistance
passive range of motion - ANSWERS-movement that is performed completely by the examiner
fowler's position - ANSWERS-a semi-sitting position; the head of the bed is raised between 45
and 60 degrees
semi-fowler's position - ANSWERS-the head of the bed is raised 30 degrees
orthopneic position - ANSWERS-sitting up and leaning over a table to breathe
sims position - ANSWERS-lying on left side with right knee drawn up and with left arm drawn
behind, parallel to the back
prone position - ANSWERS-lying face down
trendelenburg position - ANSWERS-lying on back with body tilted so that the head is lower than
the feet