CHPT. 8 vocab and questions Flashcards
Assessment
collecting information 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 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 in the care plan
medical record
the legal account of a person’s condition and response to treatment and care, chart or clinical record
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 to help the person reach a goal, 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
progress note
describes the care given and the person’s response and progress
subjective data
things a person tells you about that you cannot observe through your senses, symptoms
What kind of words should you use for communication
words that mean the same to everyone
what do we report when we do care
when there is a change from normal or a change in the person’s condition. Report these changes at once.
when the nurse asks you to do so
before leaving the unit for meals, breaks, or other reasons,
after the end-of-shift report and before reporting off duty
what are general rules for recording
follow agency policies and procedures for recording. Ask for needed training, use correct grammar or make sure it makes since, accurate, concise and factual.
you help with a person’s care. Recording on the person’s medical record violates the right to privacy.
False
medical records can be used to prove the care given
True
you can access all medical records in the agency
False
The nursing process is the method nurses use to plan and deliver nursing care
True
measures in the care plan are carried out in the assessment step of the nursing process
False
when using a computer, the person’s privacy must be protected
True
You can give information about the person over the phone
False
you can post your username and password in your work area
False
the agency can monitor your computer use
True
you should leave faxes in the fax machine for the nurse to read
false
to communicate well, you should
give facts and be specific
A person is discharged from the agency. The medical record is
permanent
where does the nurse describe the nursing care given
progress notes
you need to know if a resident uses a hearing aid you should
read the progress notes
you need to record a patients’ vital signs every hour. Where should you record the measurements
Flow sheet
your role in the nursing process involves
reporting observations
which is a symptom
vomiting
which should you report at once
the person can no longer move a body part
the care plan is
the measures to help the person
to communicate delegated tasks to you
an assignment sheet
which statement about recording is correct
record only what you did and observed
you have access to the agency’s computer. Which is true
you should log off after making an entry
A phone rings at the nurses’ station. Which greeting is best
Good morning, north hall. Joey Wilson, nursing assistant, speaking.
