Chapter 4 Communicating With The Health Team Flashcards
Abbreviations
A shortened form of a word or phrase
Care plan
A record of the measures to be offered to the best care for the residents
Chart
See medical records
Communication
The exchange of information a message sent is received and correctly interpreted by the intended person
Conflict
A clash between opposing interests or ideas
Diagnosis
The term used when symptoms signs or reasons for a problem are identified
Kardex
A type of card file that summarizes information found in the medical record medication’s treatments, diagnoses, routine care measures, equipment, and special needs
Medical record
A written or electronic document of a person conditioned and response to treatment and care of referred to as a chart, clinical record, or health record
Prefix
A word element placed before a root; it changes meaning of the word
Progress note
A written description of the care given and the persons response and progress
Recording
The written account of care and observation charting
Root
A word element that contains the basic meaning word
Suffix
A word element placed after a root; it changes the meaning of the word
Word Element
A part of a word
ADL
Activities of daily living
EHR
Electronic Health Record
EMR
Electronic Medical record
EPHI
Electronic Protected Health Information
HIPAA
Health Insurance Portability and Accountability Act
MDS
Minimum data set
OBRA
Omnibus Budget Reconciliation Act of 1987
PHI
Protected Health Information
POC
Point of Care
Under OBRA residents have the right to
Know the information in their medical records
Information about the persons adavance directive would be found in the
Admission sheet (Face Sheet)
Which of the following would not be found on the activities of daily living ADL flow sheet?
Lab Results
OBRA Requires that summaries of care (progress notes) be written at least
Every 3 months
To communicate, should do the following Except?
Use terms with many meanings
Mr. YU is discharged from the center. His medical record is
Permanent
These statements are about medical record. Which is false?
Anyone working in the center can read them
A person is weighed daily. The measurement is recorded on the
Flow sheet
Where does the nurse describe the nursing care given?
Progress notes
When recording, you do the Following Except
Erase errors
These statements are about recording. Which is false??
Chart a procedure before completing it
In the evening the clock shows 9:26. In 24-hours clock time
2126
A suffix is
Placed after a root
Which term related to the side of the body?
Lateral
These statements are about computers in health care. which is False??
All employees have the same password
You have access to centers computer. Which is true?
Email and messages are sent only to those needing the information
Mrs. Parks asks you to answer her personal phone because she is unable to reach it. How should you answer?
Good morning, Tammy brown, nursing assistant speaking.
A coworker is often late for work. This means extra work for you. To resolve the conflict, you should do the following EXCEPT?
Discuss the matter during the end -of - shift report
The written guide giving directions about the nursing care a person should receive is the
Comprehensive care plan
Flow sheets are
Used to record frequent measurements or observations
During which step of the nursing process is care given ?
Implementation
Which of the following is INCORRECT when recording on a residents chart?
Use a pencil in case you make a Mistake
You have a disagreement with a co worker about your work schedule. You should
Ask to discuss the problem with your supervisor
“A-nurse ignores me” is an example of what step in the problem solving process??
Define the problem
Anterior means
At or towards the front of the body or body part
What is the world that means inflammation of a joint?
Arthritis
Shortened forms of words or phrases are
Abbreviations
The prefix “ab” means
Away from
The medical diagnosis and the nursing diagnosis are always the same
False
The medical record is permanent legal documents
True
Everyone who works in a nursing center has the right to read the residents records
False
Assessment involves setting priorities and goals
False
You may share your computer password with other members of the health team.
False
Conflict in the work setting can affect the quality of care provided
True
Knowing medical terminology is important in your work
True
A prefix is often used alone
False
The root contains the basic meaning of the word
True
“Chest pain” is a symptom
True
