Health History & Communication Vocab Flashcards
Active listening
Paying complete attention to what another person is saying; listening closely while showing interest and refraining from interrupting.
Biographic data
Information that identifies the client, such as name, address, phone number, gender, and who provided the information.
Chief complaint
A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter.
Clarification
Offering back to the speaker the essential meaning, as understood by the listener, of what they have just said.
Clinical judgment
An iterative decision-making process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, generate the best possible evidence-based solutions in order to deliver safe client care.
Confrontation
A communication skill wherein the nurse identifies and responds, provides feedback regarding those discrepancies in a client’s behavior in such a manner that the other person can grow.
Context of Care
The elements of a client’s life or living situation that have psychological, social, and/or economic relevance to his or her use of professional health services.
Documentation
A record containing a client’s background information or nursing history including assessments, nursing care plan and progress notes.
Facilitation
To provide opportunities for personal growth in the patient; to encourage patient to continue speaking.
Genogram
A tool that nurses use gather demographic, functional status/resources, and critical events/dynamic data to provide a comprehensive, holistic picture of a client and their environment.
Health Promotion
The process of nurses providing patients the information they need to manage and ultimately improve their health enabling people to increase control over their health.
Health Protection
Nurses role in preventing the spread of communicable diseases by establishing minimum standards, often in the form of regulations, and sharing information with patients.
Objective data
Measurable information obtained by the nurse through observation, physical examination, and laboratory and diagnostic testing.
Past Health History
Is information elicited by the nurse about the patient’s childhood illnesses and immunizations, accidents or traumatic injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and chronic illnesses.
Physical Exam
A health assessment that uses inspection, palpation, percussion, and auscultation.
Present illness
A description of the present illness, injury, trauma, or chief complaint.
Primary Prevention
Prevention of exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur.
Primary source data
Information obtained by the nurse from the person who is being examined.
Reflection
A therapeutic communication technique that reflects and mirrors what the nurse believes the client’s feelings to be underneath the words.
Restatement
A communication technique where the nurse repeats the main idea of what the client has said, confirming that the client’s statement has been heard and understood.
Review of Systems
An inventory of the body systems that is obtained by the nurse through a series of questions to identify signs or symptoms that the patient may be experiencing.
Subjective data
Information obtained from the client’s point of view, including feelings, perceptions, and concerns.
Secondary prevention
A form of early disease detection that identifies individuals with high risk factors or preclinical diseases through screenings and regular care to prevent the onset of disease.
Shift assessment
A concise nursing assessment completed at the beginning of each shift where the nurses assesses specific body system(s) relating to the presenting problem or current concern(s) of the patient.
