Ch. 9 & 11 Fundamentals Of Nursing-Taylor

Front 1

medical records

Back 1

written collection of info about a person's health, care provided by doc.s/nurses and clients progress

Front 2

Chart

Back 2

binder/folder; promotes collection, storage & safe keeping of person's MR's

Front 3

Different kinds of charts:

Back 3

fact, teaching, labs, directives, Doc's orders and admission

Front 4

Quality Assurance

Back 4

internal process for self-improvement to ensure the level of care reflects or exceeds est standards

Front 5

Who does accreditation

Back 5

JCAHO

Front 6

Why do charts?

Back 6

quality assurance, accreditation, reimbursement, education, & legal evidence.

Front 7

Source-oriented

Back 7

organized according to the source of documentation

Front 8

Problem-oriented

Back 8

by the client's health problem

Front 9

Charting Methods are:

Back 9

Narrative, SOAP, FOCUS, DAR, Pie, exception & computerized

Front 10

Narrative Charting

Back 10

entry like a journal, source oriented

Front 11

SOAP Charting

Back 11

(problem oriented)
S-subjective data
O-objective data
A-analysis of data
P-plan for care

Front 12

FOCUS Charting

Back 12

modified soap charting

Front 13

Pie Charting

Back 13

record under heading:
problem intervention and evaluation

Front 14

Charting by Exception

Back 14

chart only abnormal assessment findings

Front 15

Computerized Charting

Back 15

client info electronically

Front 16

Traditional Time

Back 16

two 12 hour revolutions of the clock

Front 17

Military Time

Back 17

based on a 24 hour clock

Front 18

Written forms of Communication
(4)

Back 18

Nursing care plan, nursing Kardex, chechlists and flow sheets

Front 19

Interpersonal Communications

Back 19

change of shift report, client care assessment, client rounds and telephone

Front 20

Nursing Care plan

Back 20

list of problems, goals and nursing orders for client care

(can be revised)

Front 21

Nursing Kardex

Back 21

quick reference about client & their care

Front 22

Checklists

Back 22

nurse shows w/a check mark or initials the performance of routine care

Front 23

Flow sheets

Back 23

W/sections for recording frequently repeated assessment data

Front 24

Change of shift Report

Back 24

communication between nurse going off and nurse going on duty

Front 25

Client Care Assignment

Back 25

at the beginning of every shift, what the job will be

Front 26

Team Conference

Back 26

exchange of info in a group

Front 27

Client Rounds

Back 27

visit to clients as an individual or as a group

Front 28

telephone

Back 28

exchange of info

Front 29

Admission

Back 29

entering a health care agency for nursing care & medical or surgical treatment

Front 30

Steps in admission:

Back 30

physicians authorization, collection of billing info and completion of admission database

Front 31

Inpatient

Back 31

stay more then 24 hours

Front 32

Outpatient

Back 32

stay less then 24 hours

Front 33

Medical authorization

Back 33

determines whether a patient should be admitted

Front 34

Admission Department

Back 34

gain info about the patient's med. history, insurance ect.

Front 35

Nursing Admission activities

Back 35

-prepare the room
-welcome the client
-orient the client
-safe guard valuables
-help the client undress
-compiling the nursing database

Front 36

Initial plan for care

Back 36

ID problems and includes projected needs

Front 37

Medical admission responsibilities

Back 37

doc gives order for care

Front 38

Common responses to admission by clients

Back 38

loneliness, anxiety, decreased privacy, loss of identity ect

Front 39

Discharge

Back 39

termination of care from the health care agency

Front 40

Discharge planning

Back 40

improves client outcome

Front 41

Transfer

Back 41

discharging a client from unit or agency and admitting him/her to another w/o going home interim

Front 42

Could go to these places in transfer:

Back 42

step-down units, progressive care units &traditional care units

Front 43

What to do in Activities Transfers:

Back 43

-inform patient and family
-write a transfer summary

Front 44

Extended Care Facilities

Back 44

health care agency that provides long-term care

Front 45

Skilled Nursing Facility

Back 45

24 hour nursing care, under direction of an RN

Front 46

Intermediate Care

Back 46

care for mental and physical conditions

Front 47

Basic care

Back 47

agency that provides extended custodial care

Front 48

Continuity of Care

Back 48

uninterrupted client care despite the change in caregivers