Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
23 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
Approaches
|
What team member are going to do
|
8.91
|
|
|
Assessment
|
Collection of data/information about the patient
|
8.91
|
|
|
Care Plan Conference
|
Planning the care of the patient in a meeting with the patient and family includes: nursing diagnoses, the approaches, and the patient’s goals
|
8.91
|
|
|
Charting
|
Documentation
|
8.103
|
|
|
Critical (clinical) Pathways
|
Written documents that detail the expected course of treatment and expected outcomes for a DRG
|
8.97
|
|
|
Document
|
Medical record
|
8.103
|
|
|
Evaluation
|
Final step of nursing process determines: whether patient is reaching goal on care plan, why goals aren’t being reached, if patient is unsuccessful, what should be done to reach goals, when goals are reached – should it be extended (walking 200ft, extended 250 ft)
|
8.94
|
|
|
Flow Sheet
|
Clinical record of ongoing patient care and process
|
8.103
|
|
|
Goal
|
An outcome
|
8.91
|
|
|
Health Insurance Portability and Accountability (HIPAA)
|
Congress passed in 1996: increase patient control over personal medical records, restrict use/disclosure of patient information, make facilities accountable for protecting patient data, require facility to implement and monitor their information release policy and procedures
|
8.106
|
|
|
Implementation
|
Activation of the care plan
|
8.94
|
|
|
Intervention
|
Approach to help patients solve the problem
|
8.91
|
|
|
Kardex
|
Patient’s medical record at nurse’s station
|
8.91
|
|
|
Nurse’s Notes
|
Section of medical record in which nursing staff records procedures, medications, and observations
|
8.103
|
|
|
Nursing Diagnoses
|
The statement of a patient problem and the cause of the problem
|
8.91
|
|
|
Nursing Process
|
Collecting and communicating information about patients by reporting and documenting
|
8.90
|
|
|
Objective Observation
|
One that is factual or measurable in some way
|
8.97
|
|
|
Observation
|
Information that is obtained by using one’s senses: seeing, hearing, smelling, feeling
|
8.97
|
|
|
Oral Report
|
Method of relaying information from one person to another
|
8.102
|
|
|
Personal Digital Assistant (PDA)
|
Portable computing device
|
8.107
|
|
|
Planning
|
Developing a care plan
|
8.91
|
|
|
Subjective Observation
|
A statement or complaint made by the patient
|
8.97
|
|
|
Tablet PC (TPC)
|
Portable computing device
|
8.107
|
