Safety and Documentation Study Guide

These flashcards cover key concepts related to safety, documentation, fluid and electrolytes, and acid-base balance in patient care.

What is the purpose of a patient's written record?

It serves as a legal document, a communication tool between providers, and a basis for care planning and billing.

What should be done to ensure computer safety regarding electronic records?

Use strong passwords and log off when not in use.

What does HIPAA compliance ensure?

It ensures the protection and confidentiality of patient health information.

What are the two types of charting mentioned?

Charting by exception and Narrative charting.

Define SOAP in charting context.

SOAP stands for Subjective, Objective, Assessment, and Plan.

What is the recommended daily fluid intake?

2,000 to 3,000 mL.

What is osmosis?

The movement of water across a semipermeable membrane.

Define diffusion.

The movement of solutes from an area of high concentration to an area of low concentration.

What is filtration in the context of fluid movement?

It is the movement of water and solutes across a membrane due to pressure differences.

What systems balance acid in the body?

The Bicarbonate buffer system, Respiratory system, and Renal system.

What is hyperventilation and what effect does it have on pH?

Hyperventilation causes respiratory alkalosis due to loss of CO2, resulting in a high pH.