Communication with the health team Flashcards
Communication is
the exchange of information.
The medical record is
a written or electronic account of a person’s condition and response to treatment and care.
Admission record is completed when
the person is admitted to the center.
Health history (nursing history) is completed when
the person is admitted.
Health history contains
person’s background information and health history.
Graphic sheet is used to
record measurements and observations made daily, every shift, or three to four times a day.
Progress notes describe
the care given and the person’s response and progress.
Flow sheets are used to
record frequent measurements or observations.
The Kardex
a type of card file that summarizes information in the medical record.
Reporting is the
oral account of care and observations.
Recording (charting)
is the written account of care and observations.
When a 25-hour time begins with
zero (0) read or say the “0” as “zero” or “oh”
When using 25-hour time and the last 2 digits (minutes) end in “00,” read or say the numbers as
“hundred hours”
You must use AM and PM with
conventional time
When recording on the person’s chart, you must communicate
clearly and thoroughly.
You must keep PHI and electronic protected health information (ePHI, EPHI)
confidential.
Abdominal regions are used to describe
the location of body structures, pain, or discomfort.
RUQ
Right upper quadrant
(LUQ
Left upper quadrant
RLQ
Right lower quadrant
LLQ
Left lower quadrant
Anterior (ventral)
at or toward the front of the body or body part
Posterior (dorsal)
at or toward the back of the body or body part
Proximal
the part nearest to the center or to the point of origin
Distal
The part farthest from the center or from the point of attachment
Lateral
away from the midline; at the side of the body or body part
Medial
At or near the middle or midline of the body or body part
To communicate well, you should:
Give facts and be specific
A person is discharged from the agency. His medical record is
Permanent
The nurse uses a medical term that you do not understand. What should you do?
Look the word up in a medical dictionary
A nurse aide notices blood in a patient’s IV tubing. The aide should
Notify the IV nurse
What is a proper way to correct an error in charting?
Draw a single line through it
