Medical Terms

Question 1

What is Assessment?

Answer 1

• collecting information
• done by Nurse/Doctor
• used for creating care plans

Question 2

What is Observation?

Answer 2

• assessment done by a PSW

- observing pt, ct, or rt

Question 3

What is Nursing dx?

Answer 3

• problem statement

- planning includes Nurses, and PSW’s

Question 4

What is Physical/Medical dx?

Answer 4

• Doctor makes this

- disease process

Question 5

What is Implementation?

Answer 5

• PSW carrying out plans

- manly PSW’s job

Question 6

What is Re-evaluate?

Answer 6

• if it is working? Leave it alone

- if it is not working, start back at assessment

Question 7

What is a Care Plan?

Answer 7

-certain ADL’s based on ct’s ability

Question 8

What is DNR?

Answer 8

do not resuscitate

Question 9

What is Full Code?

Answer 9

doing anything possible to bring that ct back to life

Question 10

What is FMM?

Answer 10

full medical management in the facility

Question 11

What is 1 DNR?

Answer 11

comfort measures

Question 12

What is 2 DNR?

Answer 12

medical management at facility unless major

Question 13

What is 3 DNR?

Answer 13

transfer to hospital (FMM)

Question 14

4 Full Code?

Answer 14

do whatever is necessary to bring ct back

Question 15

What is a Care Conference? *

Answer 15

When the family of the ct and sometimes ct if they are cognitive enough have a meeting and discuss what is suitable for ct’s ADLs. This conference could consist of Nurse, Doctor, PSW, Social Worker, Physiotherapist, Occupational therapist, and Nutritionist. Anybody that is involved the ct’s day will be a part of the conference.

Question 16

What is SOAP?

Answer 16

• subjective
• objective
• assessment/action
• plan

Question 17

What is DARP?

Answer 17

• data
• assessment/action
• response
• plan

Question 18

What is Narrative?

Answer 18

writing down all of the events in sequence as you were writing it in a story

Question 19

What is documentation? *

Answer 19

• factual
• symptoms
• changes
• explain why
• 0 assumption

Question 20

What are legal ways to document?

Answer 20

• chart
• electronic chart
• flow sheets
• progress notes

Question 21

What are the not legal ways to document?

Answer 21

• verbal reporting

- written reporting

Question 22

What is a progress note?

Answer 22

-what you saw
-what you did
-accurate facts
client response
-24 hour clock
-medical abbreviations are accepted

Question 23

What is a Sender?

Answer 23

the person giving the message

Question 24

What is the Receiver?

Answer 24

the person receiving the message

Question 25

What is the Message?

Answer 25

what you want the receiver to know

Question 26

What is the Response?

Answer 26

what the receiver’s reaction was to the message

Question 27

What is Body Language?

Answer 27

receivers body movements when you are telling them the message. they tend to lean in on the conversation if they are interested in what you are saying and if they are slouching then that tends to mean they are distracted or not focused.

Question 28

What is a Mixed Message ?

Answer 28

means that the person is doing something and saying something else

Question 29

What happens to people communication skills as they age?

Answer 29

Hearing gets difficult, speaking is difficult, the nervous system starts to slowly give up. The messages aren’t passing to the brain as quickly as they should be and they aren’t as sharp either.

Question 30

What is an Incident Report?

Answer 30

a report in a workplace where a person gets hurt, and it gets reported

Question 31

What is a Flow Sheet?

Answer 31

sheets that are in hospitals documenting several changes of a patient

Question 32

What is a Progress Note?

Answer 32

a brief summary of a patients current clinical status

Question 33

What is a Graphic Sheet?

Answer 33

documentations on a patients changes