Chapter 8 Vocab Flashcards
assessment
collecting info about the person
electronic health record (EHR)
an electronic version of a person’s medical record
end of shift report
a report that the nurse gives at the end of the shift to the oncoming shift
evaluation
to measure if goals in the planning steps were met
implementation
to perform or carry out nursing interventions in the care plan
medical record
the legal account of a person’s condition and response to treatment and care
nursing care plan
a written guide about the person’s nursing care
nursing diagnosis
health problem that can be treated by nursing measures
nursing intervention
an action taken by the nursing team to help the person reach a goal
nursing process
the method nurses use to plan and deliver nursing care
- 5 steps: assessment, nursing diagnosis, planning, implementation, and evaluation
objective data
info that is seen, heard, felt, or smelled by an observer
observation
using the senses of sight, hearing, touch, and smell to collect info
planning
setting priorities and goals
progress note
describes the care given and the person’s response and progress
recording
the written account of care and observations, charting, and documentation
