Medical Records, Asepsis, and Patient
Assessment
Medical Record (MR) - ANS Written record of important information regarding a patient.
Patient - ANS The individual receiving medical care.
PPR's - ANS Paper based patient records including registration forms, health history forms,
medical record forms.
Electronic Medical Record (EMR) - ANS Computerized record of important health information.
Components of the Medical Records - ANS Includes administrative documents, clinical
documents, laboratory results, diagnostic procedure reports, therapeutic service reports,
hospital documents, and consent documents.
Medical Record Documentation - ANS Check names on the patient record before making an
entry and use clear and concise phrases when documenting.
Accuracy in Documentation - ANS Accuracy documentation and correct spelling are essential.
Timing of Documentation - ANS Document immediately after performing a procedure.
Documentation Ethics - ANS NEVER document for someone else.
Components of the Health History - ANS Includes identification data, chief complaint, present
illness, past/family/social history, and review of systems (ROS).
Subjective Symptom - ANS A feeling experienced by the patient, such as numbness or
headache.
Objective Symptom - ANS What can be observed, such as bleeding or redness.
Legal Status of Medical Record - ANS The medical record is a legal document.
Confidentiality - ANS All information in the medical record is confidential.
Infection Control - ANS Important in preventing the spread of disease.
MOA's Role - ANS Key role in providing a safe space/healthy environment.
, Infection Process Cycle - ANS Infection occurs when part of the body is invaded by a
pathogenic microorganism and can only survive if a continuous cycle is followed.
Medical Aseptic Practices - ANS Includes hand hygiene, infection control, PPE, careful disposal
of waste, good lighting, ventilation, and keeping insects out.
Exposure Control Plan (ECP) - ANS Documentation with information of protective measures to
minimize exposure.
Vital Signs - ANS Objective guideposts that provide data to determine a person's state of
health.
Body Temperature - ANS Maintained through a balance of heat produced in the body and heat
lost from the body.
Sites to Measure Temperature - ANS Mouth, axilla, rectum, ear, and forehead.
Types of Thermometers - ANS Electronic thermometers, tympanic membrane thermometers,
and temporal artery thermometers.
Pulse - ANS When the left ventricle of the heart contracts, blood is forced from the heart onto
the aorta.
Factors Affecting Pulse Rate - ANS Includes age, gender, physical activity, emotional states,
metabolism, fever, and medications.
Pulse Measurement - ANS Establishes baseline and assesses heart function.
Radial Pulse - ANS Located in wrist groove below the thumb.
Apical Pulse - ANS Stronger pulse measured at heart's apex.
Brachial Pulse - ANS Found in the antecubital space of elbow.
Temporal Pulse - ANS Located in front of the ear above eye level.
Carotid Pulse - ANS Best site for quick pulse assessment.
Respiration Rate - ANS Measures rate of breathing for vital processes.
Dyspnea - ANS Difficulty breathing or shortness of breath.
Breath Sounds - ANS Sounds caused by air moving through the respiratory tract.
Assessment
Medical Record (MR) - ANS Written record of important information regarding a patient.
Patient - ANS The individual receiving medical care.
PPR's - ANS Paper based patient records including registration forms, health history forms,
medical record forms.
Electronic Medical Record (EMR) - ANS Computerized record of important health information.
Components of the Medical Records - ANS Includes administrative documents, clinical
documents, laboratory results, diagnostic procedure reports, therapeutic service reports,
hospital documents, and consent documents.
Medical Record Documentation - ANS Check names on the patient record before making an
entry and use clear and concise phrases when documenting.
Accuracy in Documentation - ANS Accuracy documentation and correct spelling are essential.
Timing of Documentation - ANS Document immediately after performing a procedure.
Documentation Ethics - ANS NEVER document for someone else.
Components of the Health History - ANS Includes identification data, chief complaint, present
illness, past/family/social history, and review of systems (ROS).
Subjective Symptom - ANS A feeling experienced by the patient, such as numbness or
headache.
Objective Symptom - ANS What can be observed, such as bleeding or redness.
Legal Status of Medical Record - ANS The medical record is a legal document.
Confidentiality - ANS All information in the medical record is confidential.
Infection Control - ANS Important in preventing the spread of disease.
MOA's Role - ANS Key role in providing a safe space/healthy environment.
, Infection Process Cycle - ANS Infection occurs when part of the body is invaded by a
pathogenic microorganism and can only survive if a continuous cycle is followed.
Medical Aseptic Practices - ANS Includes hand hygiene, infection control, PPE, careful disposal
of waste, good lighting, ventilation, and keeping insects out.
Exposure Control Plan (ECP) - ANS Documentation with information of protective measures to
minimize exposure.
Vital Signs - ANS Objective guideposts that provide data to determine a person's state of
health.
Body Temperature - ANS Maintained through a balance of heat produced in the body and heat
lost from the body.
Sites to Measure Temperature - ANS Mouth, axilla, rectum, ear, and forehead.
Types of Thermometers - ANS Electronic thermometers, tympanic membrane thermometers,
and temporal artery thermometers.
Pulse - ANS When the left ventricle of the heart contracts, blood is forced from the heart onto
the aorta.
Factors Affecting Pulse Rate - ANS Includes age, gender, physical activity, emotional states,
metabolism, fever, and medications.
Pulse Measurement - ANS Establishes baseline and assesses heart function.
Radial Pulse - ANS Located in wrist groove below the thumb.
Apical Pulse - ANS Stronger pulse measured at heart's apex.
Brachial Pulse - ANS Found in the antecubital space of elbow.
Temporal Pulse - ANS Located in front of the ear above eye level.
Carotid Pulse - ANS Best site for quick pulse assessment.
Respiration Rate - ANS Measures rate of breathing for vital processes.
Dyspnea - ANS Difficulty breathing or shortness of breath.
Breath Sounds - ANS Sounds caused by air moving through the respiratory tract.
