Communication & Documentation

Question 1

aggressive behavior

Answer 1

standing up for one’s rights in a negative manner that violates the rights of others

Question 2

assertive behavior

Answer 2

standing up for oneself and others using open, honest, and direct communication

Question 3

CUS tool

Answer 3

communication related to patient safety concerns. concerned uncomfortable safety issue

Question 4

empathy

Answer 4

understanding how the patient feels

Question 5

horizontal violence

Answer 5

anger and aggressive behavior between nurses

Question 6

incivility

Answer 6

rude, intimidating behavior directed at another person

Question 7

intERpersonal communication

Answer 7

occurs between 2 or more people, exchanges messages

Question 8

intRApersonal communication

Answer 8

self-talk to enhance positive interaction with patient and family

Question 9

organizational communication

Answer 9

involves individuals and groups to achieve established goals

Question 10

rapport

Answer 10

mutual trust experienced by people in a satisfactory relationship

Question 11

SBAR tool

Answer 11

communication between healthcare personnel. Situation, background, assessment, recommendations

Question 12

small-group communication

Answer 12

occurs when 2 or more nurses interact with 2 or more individuals

Question 13

Bedside report

Answer 13

Standardized shift report at the bedside , helps ensure safe handoff of care between nurses

Question 14

Change of shift report

Answer 14

Used to transmit patient information to nurses who continue the care

Question 15

Charting by exception (CBE)

Answer 15

Documenting patient data only when it is does not match the standard

Question 16

Confer

Answer 16

Consult with someone, exchange of ideas or seeking information or advice

Question 17

Consultation

Answer 17

Two or more individuals with varying experience process a problem and its solution

Question 18

Critical or Collaborative pathway

Answer 18

Detailed, standardized plan of care developed for a population with a diagnosis or procedure. Has expected outcomes and interventions

Question 19

Discharge summary

Answer 19

Describes patient and their relation to problems. Can give special teaching, referrals, or counseling

Question 20

Documentation includes

Answer 20

Assessments, diagnoses, plans, interventions, and evaluations

Question 21

Electronic Health record (EHR)

Answer 21

Contains medical history, diagnoses, medications, treatment plans, immunization dates, allergies, lab results

Question 22

Flow sheet

Answer 22

Graphic record of aspects of a patient’s condition

Question 23

Focus charting

Answer 23

Focus column that includes aspects of a patient and patient care. Uses DAR. Data, action, response

Question 24

Handoff

Answer 24

Nurse’s report to another nurse about patient status and progress

Question 25

Health Information Exchange (HIE)

Answer 25

Allows healthcare providers and patients to access a patient's medical info

Question 26

Incident or variance report

Answer 26

Any event that is not valid with a Healthcare facility. Has potential to harm

Question 27

ISBAR communication

Answer 27

Handoff communication among Healthcare providers about patients condition. Identity/introduction, situation, background, assessment, recommendation/read back

Question 28

Minimum data set

Answer 28

The information that must be collected from every patient

Question 29

Narrative notes

Answer 29

Progress notes written in a source oriented record

Question 30

Occurrence or variance charting

Answer 30

When a patient fails to meet an expected outcome. Includes cause and actions taken in response

Question 31

Outcome and Assessment Information Set (OASIS)

Answer 31

Assessment instrument, core items of a comprehensive assessment for adult home health care patients. Measures patient outcomes for improving quality of care

Question 32

Patient record

Answer 32

Compilation of patients health info. Details nurse's interactions

Question 33

Personal health record (PHR)

Answer 33

Information sheets including medical history, including diagnoses, symptoms, and medications

Question 34

PIE charting

Answer 34

Incorporated into progress notes, problems are identified by number. Problem, intervention, evaluation

Question 35

Problem oriented medical record (POMR)

Answer 35

Organized according to the specific health problems, includes problem list, plan of care and progress notes

Question 36

Progress notes

Answer 36

Any method of note that relates to how a patient is progressing

Question 37

Purposeful rounding

Answer 37

Nurse driven, evidence based intervention that helps nurses anticipate and address patient needs

Question 38

Read back

Answer 38

Repeating a verbal order to ensure it was heard correctly

Question 39

SOAP Format

Answer 39

Charting narrative progress notes. Subjective information, objective information, assessment, plan

Question 40

Source oriented record

Answer 40

Each heathcare group records data on its own separate form

Question 41

bullying

Answer 41

negative, repetitive and disruptive behavior

Question 42

bullying is also referred to __ violence (2 types)

Answer 42

horizontal and lateral

Question 43

channel

Answer 43

a term used to represent the way a message is conveyed/given, can target any receiver's senses (see communication theory)

Question 44

communication

Answer 44

process of sharing information and transmitting meanings

Question 45

cliché

Answer 45

a stereotyped answer

Question 46

feedback

Answer 46

verbal and nonverbal evidence that the message is received and understood

Question 47

group dynamics

Answer 47

study of a group's (population of people) characteristics and ways of functioning

Question 48

helping relationship

Answer 48

interaction that sets the pace towards common goals for the patient or participants

Question 49

language

Answer 49

prescribed way of using words, a way to express feelings and thoughts

Question 50

message

Answer 50

a term used to describe the physical product of the source, a speech or phone call (see communication theory)

Question 51

noise

Answer 51

factors the distort the quality of a message, interferes with communication process

Question 52

semantics

Answer 52

study of the meaning of words

Question 53

graphic record

Answer 53

form used to record specific patient variables

Question 54

referral

Answer 54

process of sending or guiding someone to another source for assistance