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Communication Types

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