Observation and Reporting Skills Vocabulary Flashcards
1
Q
Medical Charts
A
Charts on which healthcare professionals jot down observations or record patient care
2
Q
Observation
A
The recording or noting of something by a healthcare professional about a patient or client
3
Q
Patient Observations
A
Observations about a patient’s condition
4
Q
Progress Notes
A
Notes that show activities completed with patients or on their behalf
5
Q
Relevant Report
A
A report that contains information closely connected with the matter being related
6
Q
Reporting
A
Written documentation or verbal communication of any atypical events or changes in behavior or condition during patient care
7
Q
Sequential Order
A
A system of organizing information by the order in which events occurred
