Electronic Medical Record Basics

These flashcards cover key concepts and details from the Electronic Medical Record Basics lecture, focusing on patient information, vital signs, and the significance of medical documentation.

What is included in a patient's electronic medical record (EMR)?

Progress notes, chief complaint, HPI, past medical history, surgical history, family history, social history, testing, labs, medications, and allergies.

What does HPI stand for in medical records?

History of Present Illness.

Why is it important to document a patient's past medical history?

It provides context for the patient's current health and helps guide treatment decisions.

What does 'sign' refer to in medical terminology?

Objective information that can be observed or measured.

What is a symptom in medical terminology?

Subjective information reported by the patient.

What is the normal range for adult oral temperature?

97.6 to 99.6 degrees Fahrenheit.

What are the normal ranges for adult blood pressure?

Systolic 90-119 mm Hg and Diastolic 60-79 mm Hg.

What is the significance of baseline vital signs?

It establishes what is normal for that particular patient and provides a reference for future assessments.

What type of information should be included in a patient's allergy documentation?

Any medications that a patient has been allergic to, and it is important to include specifics to ensure patient safety.

What is the normal pulse rate for adults?

60 to 100 beats per minute.

What do you assess when measuring respiration?

The number of breaths per minute, quality of breaths (labored or unlabored), and any abnormalities.

What does SpO2 measure?

Oxygen saturation in the blood.

What should you never do when palpating a pulse?

Never use your thumb to palpate a pulse.

What is the significance of blood pressure readings?

They can indicate the state of a person's cardiovascular health and help diagnose conditions like hypertension.

What can cause abnormal baseline vitals?

Factors such as anxiety, pain, dehydration, and medical conditions can cause changes.

Why is it important for healthcare providers to listen to their patient's symptoms?

Listening to symptoms can help diagnose conditions and provide better patient care.