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Related Flashcards
Cards In This Set
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chart
medical record |
A written or electronic account of a person's condition and response to treatment and care.
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communication
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The exchange or information - a message sent is received and correctly interpreted by the intended person.
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comprehensve care plan
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A written guide about the person's care; care plan.
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nursing process
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The method nurses use to plan and deliver nursing care; its five steps are
1. Assessment 2. Nusing diagnosis 3. Plannig 4. Implemention and 5. Evaluation |
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objective data
signs |
Information that is seen, heard, felt, or smelled by an observer; signs
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observation
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Using the senses of sight, hearing, touch and smell to collect information. |
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recording
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The written account of care and observations; charting.
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reporting
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The oral account of care and observations.
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subjetiv data
symptoms |
Things a person tells you about that you cannot observe through your senses.
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MDS
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Minimum Data Set
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NANDA-I
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North American Nursing Diagnosis Assocation International
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OBRA
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Omnibus Budget Reconciliaion Act of 1987
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PDA
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Personal digital assistant
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PHI
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Protected health information
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RAPs
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Resident Assessment Protocols
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