Ch.7 Health Team Communication Key Terms and Abbreviations Flashcards
ADL
Activities of daily living
BM
Bowel Movement
CMS
Centers for Medicare and Medicaid Services
EHR
Electronic health record
EMR
Electronic medical record
EPHI; ePHI
Electronic protected health information
MDS
Minimum Data Set
PHI
Protected health information
Assessment
Collecting information about the person
Electronic health record (EHR)
An electronic version of a person’s health record; electronic medical 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
Implementation
To perform or carry out nursing interventions (nursing measures; nursing actions, nursing tasks) in the care plan
Medical record
The legal account of a person’s condition and response to treatment and care; chart
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 intervention
An action or measure taken by the nursing team to help the person reach a goal; a nursing action, nursing measure, nursing task
Nursing process
The method nurses use to plan and deliver nursing care; its 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 senses of sight, hearing, touch, and smell to collect information
Planning
Setting priorities and goals
Recording
The written account of care and observations; charting; documentation
Reporting
The oral account of care and observations
Subjective Data
Things a person tells you about that you cannot observe through your senses; symptoms
