CNA Chapter 7

Health Team Communications

assessment

collecting information about the person

chart/medical record

the legal account of a person’s condition and response to treatment and care; care plan

electronic health record (EHR)/ electronic medical record

an electronic version of a person’s medical record

end-of-shift report

a report that the nurse gives at the end of the shift to the on-coming shift; change-of-shift report

evaluation

to measure if goals in the planning step were met

implementation

to perform or carry out nursing interventions (nursing measures, nursing actions, nursing tasks) in the care plan

nursing care plan

a written guide about the person’s nursing care; care plan

nursing diagnosis

a health problem that can be treated by nursing measures

nursing intervention

an action or measure taken by the nursing team to help the person reach a goal; nursing action, nursing measure, nursing task

objective data

information that is seen, heard, felt, or smelled by an observer; signs

nursing process

the method nurses use to plan and deliver nursing care; its 5 steps are assessment, nursing diagnosis, planning, implementation, and evaluation

observation

using the senses of sight, hearing, touch, and smell to collect information

planning

setting priorities and goals

recording

the written account of care and observations; charting and documenting

subjective data/ symptoms

things a person tells you about that you cannot observe through your senses