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48 Cards in this Set
- Front
- Back
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Word Element
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A part of a word
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Prefix
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A word element placed before a root; it changes the meaning of the word
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Root
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A word element containing the basic meaning of the word
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Suffix
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A word element placed after a root; it changes the meaning of the word
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PHI
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Protected Health Information
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Abbreviation
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A shortened form of a word or phrase
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Communication
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The exchange of information-A message sent is received and correctly interpreted by the intended person
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Conflict
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A clash between opposing interests or ideas
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Medical Record/Clinical Record/Chart
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A written record account of a person's condition & response to treatment & care
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Progress Note
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A written description of the care given & the person's response & progress
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Kardex
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A type of card file that summarizes information found in the medical record - drugs, treatments, diagnosis, routine care measures, equipment and special needs
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Reporting
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The oral account of care and observations
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Recording
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The written account of care and observations
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Explain why health team members need to communicate
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To give coordinated & effective care to patients. What was done, What needs to be done, and the resident's response to treatment. The resident knows they aren't neglected or forgotten as a result.
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Rules of Good Communication
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1. Use words that mean the same thing to you and the receiver. Avoid words with more than one meaning.
2. Use familiar words. If someone is using an unfamiliar/strange term, ask what it means. Avoid terms that the person & family do not understand. 3. Be brief & concise. Do not add unrelated or unnecessary information. Stay on the subject. 4. Give information in a logical & orderly manner. Organize thoughts and present them in an step-by-step way. 5. Give facts & be specific. Give the receiver a clear picture of what you are saying. |
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The purpose, parts, and information found in the medical record.
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It is a permanent, legal document(evidence). Each page has the resident's name-room & bed number and other identifying information (helps prevent errors & improper placement of records)
This chart is a written account or a resident's condition(s), response to treatment(s), and their care. |
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Medical Record/Chart includes...?
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Admission Sheet, Health History, Physical Exam Results, Doctor's Orders, Doctor's Progress Notes, Progress Notes (Nursing & Health Team), Graphic Sheet, Flow Sheet(s), Laboratory Results, X-ray Reports, IV therapy record, Respiratory therapy record, Consultation Reports, Assessments from nursing-social services-dietary services-and-Recreational Therapy, Special Consents. Each member on the health team records on the forms for their dept.
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The legal & ethical aspects of medical records.
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It is a legal document that may be used as evidence of the person's problems, treatment, and care & response. Know centers policies on medical records and who can see them. The policies address: who records, when to record, abbreviations, correcting errors, ink color, signing entries. Professional Staff involved in a person's care can review charts. Cooks, laundry, housekeeping and office staff do not need to read the charts. If your center does not allow you to read charts, the nurse will share needed information. **You have a legal duty to keep the resident's information confidential. If you are not involved in a resident's care~you have no right to view the person's chart. Viewing a person's chart when you don't care for them is an invasion of privacy.
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Resident requests to see or have a copy of their medical records:
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Whether the resident or their legal representative~advise you will inform the nurse of their request.
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Admission Sheet
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Completed upon resident being admitted to the center. It has name, date of birth, age, gender, address, marital status, resident's legal agent contact info, includes Medicare or SS#, known allergies, diagnoses, date & time of admission, doctor's name, religion and church or place of worship. Each resident receives an ID number that is on the admission sheet. Documented whether or not resident has made Advance Directive decisions.
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Advance Directives
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A document stating a resident's wishes about healthcare when they can no longer make their own decisions. Usually contain type of care that want if seriously ill or dying. May forbid certain care if no hope of recovery. Living Wills & Durable Power of Attorney for healthcare are common in Advance Directives.
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Living Will
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Document about measures that support or maintain life when death is likely. Tube feeding, ventilators and resuscitation are examples. It may instruct doctors: Not to start measures that prolong dying or To remove measures that prolong dying.
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Durable Power of Attorney for Healthcare
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This document gives the power to make health care decisions to another person. That person is often called a "health care proxy"-this is usually a family member, friend, or lawyer. When a person can no longer make health care decisions, the health care proxy can do so. This document does not cover property or financial matters.
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"Do Not Resuscitate" Order
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Written orders from Doctors for terminally ill persons. "Do Not Resuscitate"(DNR) or "No Code" orders. The person will not be resuscitated. The person is allowed to die with peace & dignity. The orders are written after consulting with the person & family. If the person is not mentally able to make the decision, the family & doctor will or the health care proxy may advise of advance directives that address resuscitation choices made by the person.
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Legal Issues
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When death is sudden and unexpected~every effort is made to save the persons life. Some people don't want machines or other measures used to keep them alive. Consent is needed for any treatment. When able, the person makes care decisions. Some people make end-of-life wishes known through advance directives, living wills and durable power of health care. You MUST follow the person's or family's wishes and the doctors orders~it doesn't matter if you agree with care and resuscitation decisions. A lot of attention is given to the right to die. Persons have the right to accept or refuse treatment. And they have the right to make advance directives per The Patient Self-Determination Act & The Omnibus Budget Reconciliation Act of 1987-A person has the right to die in peace and with dignity.
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Progress Notes
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Written description of the care given, the person's response, and progress. Nurse records: Signs & Symptoms, Information about treatment & drugs, Information about counseling & teaching, Procedures performed by the doctor, visits by other health team members. ***Progress notes are written when there is an unusual event, a problem, or a change in the person's condition. Have to be written at least every 3 months and reflect the person's progress toward goals set in care plan as well as the person's response to care.
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Flow Sheets
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The activities of daily living (ADL) flow sheet is used to record a person's ability to perform ADL. Addresses hygiene, food, fluids, elimination, rest, sleep, activities, and social interactions. Often used for record frequent measurements & observations: Intake & Output
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Purpose of the Kardex
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A type of card file. It summarizes information found in the medical record:meds,treatments,diagnoses,routine care,equipment,special needs
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Information to be reported to the nurse
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-Care & Observations
-Whenever there is a change from normal or a change in the person's condition**REPORT THESE CHANGES IMMEDIATELY! -When the nurse asks you to do so -When you leave the unit for breaks, meals, etc -Before end-of-shift report |
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Rules for Recording
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-You must communicate clearly & thoroughly-should reflect:what you observed, what you did, and the resident's response
-Include date & time (format according to center's policy) -Use only center approved abbreviations -Use correct grammar, spelling and punctuation -Do not use ditto marks -Sign all entries with your name and title -Make sure resident's name,room & bed number are on all pages along with any other identifying information -Record only what you observed and did yourself. Do not record for another person -Never chart a procedure, treatment or care measure until after it is completed. -Be accurate, concise, and factual. Never record judgements , interpretations or opinions. -Record in a logical and sequential manner. -Be descriptive -Use the resident's exact words whenever possible and use quotation marks. -Chart any changes from normal or in the patients condition. Also chart that you informed the nurse (include nurses name)what you told the nurse and time of the report to the nurse -DO NOT OMIT I |
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Rules for Reporting
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-If not sure, ask nurse
-Give Accurate descriptions & precise measurements -Be prompt, thorough, and accurate -Have resident's name,room and bed number -Have the time your observations were made or the care was given -Report only what you observed or did yourself -Report care measures that you expect the person to need ie a bedpan when I am at my lunch -Report expected changes in the person's condition ie. tired after physical therapy -Give reports when nurse wants you to or as often as the person's condition requires -Use handwritten notes for reporting to the nurse |
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Charting: Paper
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Always use ink.
Make sure the writing is readable and neat. NEVER ERASE OR USE CORRECTION PRODUCT! Draw a line through the error-date and initial the line. Write "mistaken entry" over if this is the center's policy.--------------- Then re-write the entry. Do not skip lines. Draw a line to the end of the sentence (as above). |
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Charting Electronic
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Log in using username/password assigned to you.
NEVER CHART USING ANOTHER'S LOG IN OR VICE VERSA. Check the time entry is made to make sure it is correct. Determine what time base is used (military with midnight as 2400 or 0000 - or converntional time. Enter information for yourself never someone else's. Only what you observed or did yourself and have completed. Check for accuracy, review your entry before saving. **SAVE ENTRIES** Log off when done charting ALWAYS!!! |
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How computers & other electronic devices are used in healthcare.
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Computer Systems:
Collect, Send, Record, and Store information, to be retrieved when needed. They store charts and care plans. Computers and faxes are used to send messages and reports to the nursing unit. They are used for measurements like vital signs. They can sense normal and abnormal measurements and alert staff by alarm when abnormal is sensed. They are used to access, send, receive, or store protected health information (PSI) confidentially |
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Explain how to protect the right to privacy when using computers and other electronic devices.
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You must keep all PHI and electronic protected health information confidential.
*Never tell anyone your log in or password:don't write it down and leave where it can be seen or found. *Follow Center policy~change password often *Never use someone else's log in & password *Follow rules for Electronic Charting *Enter data carefully, double check entries. *Prevent others from viewing computer screen: Sit with back to wall, Be aware of anyone behind you, position monitor so screen can't be seen, do not leave computer unattended. Log off after making an entry. *Don't leave print outs where they can be seen or read by others *Follow center policy on shred/detroy documents or worksheets with psi *Send emails only to those needing the information. Do not use email for needing immediate responses or information. *Do not use email or messages to report confidential information (this includes:address,phone #,and ss#) *Remember anyone may end up reading your email or retreiving it. *Center has the right to monitor yo |
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Describe the rules for answering phones.
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You may answer phones at the nurses' station or resident's rooms. Your voice gives alot of information: your tone, speed, clarity and overall attitude. Be sure to behave as if you are speaking to someone face-to-face. Be professional, courteous and always practice good work ethics. Follow center policy.
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Phone Guidelines
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*Try to answer calls after the first ring if possible, but surely by the 4th ring.
*Do not answer in a rushed or hasty manner. *Give a courteous greeting. Identify the nursing unit, and give your name and title. ie. "Good morning, Nursing South Side Floor. This is Midge Nicholson, nursing assistant, how may I assist you?" *If taking a message, write: *Caller name & number include area code and extension (repeat back to verify correct) *The date & time *Message (repeat back to verify correct) *Give the message to the appropriate person. *If have to place on hold: *Get callers name, ask permission to place on hold. Return to the caller within 30 seconds and ask if they wish to continue holding or would like a callback. **NEVER PUT AN EMERGENCY CALL ON HOLD** ***DO NOT lay the phone down or cover the receiver with your hand when not speaking to the caller. The caller may overhear confidential conversations. *DO NOT give confidential information to any caller! Residents and employees information i |
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Explain how to problem solve and deal with conflict.
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If you have a hard time talking to somone with whom you have a conflict, letting the problem or issue continue only makes the matter worse.
People bring their:values, attitudes, opinions, experiences and expectations to the work setting. Differences often lead to conflict. People disagree and argue, There are misunderstanings and unrest. Conflicts arise over issues or events. ie-work schedules, absences, the amt of work, or the quality of work. The problems must be worked out. Otherwise, unkind words or actions may occur. The work setting becomes unpleasant and tense. RESIDENT CARE IS AFFECTED!!! To resolve conflict, identify the real problem. Communication and good work ethics help prevent and resolve conflicts. Identify & solve problems before they become major issues. |
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6 Steps for Problem Solving Process
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1)Define the problem
2)Collect information about the problem. Do not include unrelated information. 3)Identify possible solutions. 4)Select the best solution. 5)Carry out the solution. 6)Evaluate the results. |
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To resolve Conflict:
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1)Ask supervisor for some time to talk privately. Explain the problem. Give facts & specific examples. Ask for advice in solving the problem
2)Approach the person with whom you have the conflict. Ask to talk privately. Be polite & professional. 3)Agree on a time & place to talk 4)Talk in a private setting. No one should hear you or the other person. 5)Explain the problem & what is bothering you. Give facts & specific behaviors. Focus on the problem. DO NOT FOCUS ON THE PERSON!!! 6)Listen to the person, Do not interupt. 7)Identify ways to solve the problem. Offer your thoughts. Ask co-worker's ideas. 8)Set a date & time to review the matter. 9) Thank the person for meeting with you 10)Carry out the solution. 11)Review the matter as scheduled. |
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Explain how to promote QUALITY OF LIFE.
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Effective & coordinated care requires health team communication. Communication MUST be:
Factual, Concise, and understandable. It should be presented in a logical way. This helps provide High-quality resident care. FALSE OR INCOMPLETE INFORMATION CAN HARM PEOPLE!! Resident information is personal & confidential. ALWAYS protect the right to privacy!! Share information with the only the health team members involved in the person's care!!!! NEVER share information with the person's family or friends without the patient's consent. |
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Medical Terminology
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Someone may use a word or phrase that you do not understand, if so, ask a nurse to explain its meaning.
If you don't understand words/phrases being used-communication is not happening. A medical dictionary is useful for learning new words & terms All works are made up of parts called elements-prefixes, roots, and suffixes. Most are from Greek or Latin. They are combined to form medical terms. TO TRANSLATE A TERM: SEPARATE THE WORD INTO ITS ELEMENTS! **Remember** Medical terms are formed by combining word elements. Prefixes are always before roots. Suffixes are always after roots. Roots can be combined with prefixes,roots and suffixes!! ie. Endocarditis-means inflammation of the inner part of the heart. Prefix (endo-inner) the root (card-heart), and the suffix (itis-inflammation). |
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Prefix
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A word element placed before a root word. *Prefixes are always combined with other word elements, they are never used alone.
ie. Oliguria means scant amount of urine. olig(scant or small amount) and uria (urine). |
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Root
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The word element that contains the basic meaning of the word. It is combined with another root word, with prefixes, and with suffixes. A vowel (an o or an i) is added when two roots are combined or when a suffix is added to a root. The vowel makes the word easier to pronounce.
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Suffix
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A word element placed after the root. It changes the meaning of the word. They are never used alone. When translating medical terms, begin with the suffix.
ie. nephritis-means inflammation of the kidney. It was formed by combining root (nephro-kidney) and suffix (itis-inflammation) |
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Abdominal Region(s):
The abdomen is divided into 4 regions. They are used to describe the location of body structures, pain, or discomfort. |
They are:
1)Right Upper Quadrant (RUQ) is from belly button to right and from belly buttion to top of head 2)Left Upper Quadrant (LUQ) is from belly button to left side and from belly buttion to top of head 3) Right Lower Quadrant (RLQ) is from belly button to right side and from belly button to bottom of right foot 4)Left Lower Quadrant (LLQ) is from belly button to left side and from belly button to bottom of left foot |
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Directional Terms-There are 6 directional terms that describe the position of one body part in relation to another. These terms give the direction of the body part when a person is standing and facing forward.
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Anterior-(ventral) at or toward the front of the body
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 Posterior-(dorsal) at pr toward the back of the body or body part Proximal-the part nearest to the center or to the point of origin. |
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Abbreviations
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Shortened forms of words or phrases that save time and money. Each Center has a list of accepted abbreviations. OBTAIN THE LIST WHEN YOU ARE HIRED! Use only those accepted by your Center. If not sure that an abbreviation is acceptable-write the term out in full. This promotes accurate communication.
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