Rent 9780827377899 | Delmar's Clinical Handbook for the Health Care Professional

Summary Table of Contents

This pocket handbook provides allied health and nursing students and professionals with essential skills in medical documentation, medical assessment, and medical procedures. The majority of the content is organized in a simple chart format to provide quick and easy reference. The managed care environment is emphasized throughout the handbook to meet the needs of today's health care professional.

Preface

xiii

Acknowledgments

SECTION 1 MANAGED CARE

Introduction

(2)

Medical Records Management Checklis... MORE

(6)

SECTION 2 MEDICAL DOCUMENTATION

Introduction

(2)

Chief Complaint

(2)

Follow-Up Appointments/Progress Notes

(1)

Documenting Medications

(2)

Documenting Prescriptions

(1)

Charting In-House Procedures

(2)

Charting Outside Procedures

(2)

Telephone Triage

(4)

SECTION 3 MEDICAL ASSESSMENT

Introduction

(2)

Important Information About the Charts

(2)

Abbreviation and Code Key

(3)

Abdominal Pain

(2)

Back Pain

(2)

Burns

(2)

Chest Pain

(2)

Cold Symptoms (Sore Throat, Congestion, Cough)

(2)

Eye Disorders

(2)

Fever

(2)

Headache

(2)

Head Injury

(2)

Insect Stings or Bites

(2)

Lacerations, Punctures, Abrasions and Bleeding

(2)

Rashes and Skin Disorders

(3)

Stomach, Pain, Nausea, Vomiting, and Diarrhea

(2)

Strains, Sprains, and Fractures

(1)

Urinary Symptoms

(1)

Vaginal or Penile Symptoms

(4)

SECTION 4 OBSTETRICS AND GYNECOLOGY

Introduction

(1)

Annual Pap and Pelvic Exam

(2)

Common Gynecological Disorders

(1)

Female Vaginal Disorders

(2)

Female Reproductive Diseases and Disorders

(3)

Gynecological Diagnostic Tests and Procedures

(2)

Routine Prenatal Exam

(2)

Obstetrical Diseases and Disorders

(4)

Obstetrical Diagnostic Tests and Procedures

(5)

SECTION 5 PEDIATRICS

Introduction

(1)

Pediatric Routine Procedures Sample Chart

(1)

Immunization Schedule

(1)

General Pediatric Assessment Sample Chart

(2)

Common Pediatric Diseases and Disorders

(5)

SECTION 6 MEDICATIONS

Prescription Abbreviations

(1)

Parts of the Prescription

(2)

Drug Classifications

101

(3)

Most Commonly Prescribed Brand-Name Medications

104

(8)

Most Commonly Prescribed Generic Medications

112

(4)

Over-the-Counter Medication Instructions

116

(2)

Over-the-Counter Medication Questions

118

(1)

Leading Over-the-Counter Medications

119

(3)

Dosage Calculations and Formulas

122

(4)

Converting Measurements

126

(6)

SECTION 7 INSTRUMENTS

Introduction

132

(2)

Illustrations of Instruments

134

(10)

SECTION 8 TRAY SETUPS

Introduction

144

(1)

Complete Physical Exam

145

(1)

Cyst Removal Tray

146

(1)

Eye, Ear, Nose, and Throat Tray

147

(1)

Electrosurgical Tray

148

(1)

Incision and Drainage Tray

149

(2)

Injecting a Joint Tray

151

(1)

Laceration/Suture Tray

152

(1)

Pap and Pelvic Tray

153

(2)

Rectal Exam Tray

155

(1)

Sigmoidoscopy Tray

156

(1)

Suture Removal Tray

157

(3)

SECTION 9 PROCEDURES, TIPS, AND FACTS

Introduction

160

(1)

Clinical Procedures

Bandaging

161

(2)

Ear Irrigation/Lavage

163

(1)

Electrocardiograms

164

(3)

Eye Irrigation/Lavage

167

(1)

Injections

Intradermal Injection

168

(1)

Intramuscular Injection (Deltoid)

169

(1)

Intramuscular Injection (Dorsogluteal)

170

(2)

Intramuscular Pediatric Injection

172

(2)

Subcutaneous Injection

174

(5)

Positioning

175

(3)

Surgical Procedures

178

(1)

Vital Signs

Blood Pressure

179

(2)

Pulse

181

(2)

Respiration

183

(2)

Temperature

185

(2)

Laboratory Procedures

Capillary Specimen Collection Facts

187

(2)

Hematocrit

189

(2)

Phlebotomy

Phlebotomy Tips

191

(1)

Hemolysis Prevention Tips

191

(1)

Butterfly Method

192

(1)

Syringe Method

193

(1)

Vacutainer Method

194

(8)

Test Kit Guidelines

195

(1)

Vacutainer Stopper

196

(2)

Chemical Urinalysis

198

(4)

SECTION 10 LABORATORY TESTS AND VALUES

Introduction

202

(1)

Common Chemistry and Serological Tests

203

(3)

Routine Hematology Tests

206

(4)

SECTION 11 DIAGNOSTIC IMAGING

Introduction

210

(1)

Information Needed When Ordering Xrays

211

(1)

Routine Flat Films

212

(2)

Ultrasound

214

(1)

Computerized Tomography (CT Scan)

215

(1)

Magnetic Resonance Imaging (MRI)

216

(2)

SECTION 12 BLANK FORMS

Managed Care

Pre-Certification Form

218

(1)

Plan Information Form

219

(1)

Participating Providers

220

(1)

Medical Assessment

General Complaint Form

221

(1)

Pediatric

Pediatric Routine Procedures Form

222

(1)

General Pediatric Assessment Form

223

(2)

Medication

Over-the-Counter Adult Chart

225

(2)

Over-the-Counter Pediatric Chart

227

(2)

Laboratory Procedures

Test Kit Log

229

(2)

References

231

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