ACSR flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Minimum necessary standard

A privacy rule requirement to disclose only the least protected health information needed to accomplish the intended purpose of a request.

Breach notification deadline

Affected individuals must be notified without unreasonable delay and no later than 60 days after discovery of a privacy breach.

Informed consent elements

Capacity, disclosure of risks, benefits and alternatives, voluntariness of the decision, and documentation of the discussion.

Mandatory reporting triggers

Suspected child, elder, or dependent adult abuse and specified communicable diseases that must be reported to designated authorities.

Scope of practice

The legally defined set of tasks a credentialed professional may perform; tasks outside it require delegation or referral.

Primary survey order

Airway, breathing, circulation, disability, and exposure, reassessed after each intervention during an emergency assessment.

Late sign of shock

Hypotension appears after compensatory tachycardia and narrowing pulse pressure; waiting for it delays recognition of deterioration.

Glasgow Coma Scale threshold

Scores range from 3 to 15; a score of 8 or below prompts assessment for airway protection.

Adult respiratory rate range

Normal adult respiratory rate is 12 to 20 breaths per minute, with oxygen saturation normally 94 to 100 percent.

Pain assessment standard

Patient self-report is the reference standard; numeric 0 to 10 or faces scales are used for those unable to use numbers.

Allergy documentation requirements

Record the offending agent, type and severity of reaction, and date before any medication is administered.

Delegation decision rule

Task stability, predictability, and required clinical judgment determine whether unlicensed staff may perform it.

Two patient identifiers

Identity is verified using two independent identifiers, such as name plus date of birth, before procedures or medication administration.

Sterile field boundaries

Sterile items must not contact nonsterile surfaces; reaching over the field or contact with unsterile objects contaminates it.

Pre-procedure time-out

A verbal team confirmation of patient, site or side, procedure, and consent immediately before an invasive procedure begins.

Specimen labeling timing

Labels are applied at the bedside immediately after collection; unlabeled specimens are rejected by the laboratory.

Sharps safety rule

Needles are never recapped by hand; safety devices are activated and the item disposed in a puncture-resistant container at point of use.

Procedure documentation contents

Indication, consent, technique, findings, specimens obtained, patient tolerance, and any complications are recorded after the procedure.

Five hand hygiene moments

Before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, and after contact with surroundings.

Airborne precautions

Used for tuberculosis and measles; requires a fit-tested N95 respirator and a negative-pressure room where available.

High-alert medications

Anticoagulants, insulin, opioids, and concentrated electrolytes carry elevated harm risk and require independent double-checks.

Root cause analysis focus

The process examines system and process failures rather than individual blame, producing measurable, tracked corrective actions.

Error prevention hierarchy

Controls ranked from strongest to weakest: elimination, substitution, engineering controls, administrative controls, then personal protective equipment.

Incident reporting principle

Reporting is non-punitive and timely; the incident report supplements but never replaces documentation in the clinical record.

Late entry labeling

An entry written after the fact is marked as late and includes both the actual entry date and the date of the event.

Chart correction method

Draw a single line through the error, initial it, and add the correct information; erasure and correction fluid are prohibited.

Documenting patient refusal

Record what was refused, the risks explained, the patient's stated reason, and notification of the responsible provider.

Prohibited abbreviations

Abbreviations such as U for unit and QD are banned because they are frequently misread; use the approved abbreviation list.

Objective documentation language

Describe measurable findings such as size, color, amount, and duration instead of judgmental terms like good or appears fine.

Four ethical principles

Autonomy, beneficence, nonmaleficence, and justice guide clinical decisions alongside veracity and fidelity obligations.

Informed refusal standard

Refusal requires the same capacity and disclosure standards as consent, plus documentation of the refusal and its stated reason.

Escalation communication script

State the concern, present the supporting facts, make a specific request, and escalate up the chain of command if unresolved.