Chapter 7: Health Team Communications Flashcards
The method nurses use to plan and deliver
nursing care; its 5 steps are assessment, nursing diagnosis, planning, implementation, and evaluation
Nursing Process
The legal account of a person’s condition
and response to treatment and care; chart
Medical Record
An electronic version of a person’s medical record; electronic medical record
Electronic Health Record (EHR)
A report that the nurse gives at the end
of the shift to the on-coming shift; change-of-shift report
End-of-shift Report
Collecting information about the person
Assessment
To measure if goals in the planning step were
met
Evaluation
To perform or carry out nursing
interventions (nursing measures, nursing actions, nursing
tasks) in the care plan
Implementation
A written guide about the person’s nursing care; care plan
Nursing Care Plan
A health problem that can be treated by
nursing measures
Nursing Diagnosis
An action or measure taken by the nursing team to help the person reach a goal; nursing
action, nursing measure, nursing task
Nursing Intervention
Information that is seen, heard, felt, or
smelled by an observer; signs
Objective Data
Using the senses of sight, hearing, touch, and smell to collect information
Observation
Setting priorities and goals
Planning
The written account of care and observations;
charting, documentation
Recording
The oral account of care and observations
Reporting
