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Nursing Assistants

Health Team Communication CH 8

TermDefinition
assessment Collecting information about the person; see "nursing process"
chart "medical record"
clinical record "medical record"
electronic health record (EHR) An electronic version of a person's medical record; electronic medical record
electronic medical record (EMR) "electronic health record"
end-of-shift report A report that the nurse gives at the end of the shift to the on-coming shift; change-of-shift report
evaluation To measure if goals in the planning step were met; "nursing process"
implementation To perform or carry out nursing interventions (nursing measures, nursing actions, nursing tasks) in the care plan, nursing process
medical record The legal account of a person's condition and response to treatment and care; chart or clinical record
nursing care plan A written guide about the person's nursing care; care plan
nursing diagnosis A health problem that can be treated by nursing measures; nursing process
nursing intervention An action or measure taken by the nursing team to help the person reach a goal; nursing action, nursing measure, nursing task
nursing process The method nurses use to plan and delivery nursing care; it's 5 steps are assessment, nursing diagnosis, planning, implementation, and evaluation
objective data information that is seen, heard, felt, or smelled by an observer; signs
observation Using the sense of sight, hearing, touch, and smell to collect information
planning Setting priorities and goals; nursing process
progress note Describes the care given and the person's response and progress
recording The written account of care and observations; charting, documentation
reporting The oral account of care and observations
signs "objective data"
subjective data Things a person tells you about that you cannot observe through your senses; symptoms
symptoms subjective data
ADL Activities of Daily Living
BMs Bowel movements
CAA Care Area Assessment
CMS Centers for Medicare & Medicaid Services
EHR Electronic health record
EMR Electronic medical record
EPHI; ePHI Electronic protected health information
IDCP Interdisciplinary care planning
MDS Minimum Data Set
OASIS Outcome and Assessment Information Set
PHI Protected health information
Created by: Natashaloreen3
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