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STNA Communication

Communication Types

Medical Record Legal document or pt chart containing health information & actions of healthcare staff
Care Plan/Plan of Care Contains goals for the pt and steps on how to achieve those goals. Defines care to be provided.
Kardex Condensed or mini-care plan. Details day to day care and pt's ability to perform ADLS.
ADL Activity of Daily Living. Things one does each day to care for self, such as brushing teeth, using cup, dressing, etc
Comprehensive Assessment Document which contains all information needed about pt, including medical/surgical history, next of kin, funeral home desired, etc.
Care Conference Meeting with all persons caring for pt including family. Purpose is to review & revise care plan.
Aphasia Inability to understand communication. Expressive is inability to speak. Receptive is inability to talk.
Charge Nurse RN or LPN supervising the rest of the staff. This is the person all problems are reported to.
Report Giving information about your pts to the oncoming shift of care givers.
Cueing Assisting a pt to complete an ADL by refocusing their attention & reminding them of what to do next
Subjective Information that only the pt can tell you from his/her point of view (ie- pain).
Objective Information you gather using one of your senses.
Verbal Communication Words, sounds (either spoken or written) used to send a message.
Non-Verbal Communication Information given through body language, gestures, facial expressions & tone of voice.
Confidentiality Keeping information about pts to yourself
Culture System of beliefs, values, traditions & behaviors a pt learns from the people they grow up with.
Charting Mistake Error in charting. Correct by drawing line through item & initial. Do not white-out.
Graphic Sheet Table used for documenting information, such as vital signs or intake/output.
MAR Record of medications given by nurse
Telephone Etiquette Answering the phone with a smile & pleasant voice by the 3rd ring. Identify yourself by name & title.
Physician's Orders/Authority Statements of what needs to be done for pt. May only be taken down by nurse.
Behavioral Care Plan Interventions to be done for residents with behavioral issues. Must be followed closely.
Created by: mrskgo