Nursing: Unit 1: Chapter 7: Health Team Communication

Medical Record

Legal account of a person’s condition and response to treatment and care

Electronic Health Record (EHR) (EMR)

Electronic version of a person’s medical record

Assessment, nursing diagnosis, planning, implementation, evaluation

Nursing Process

Method nurses use to plan and deliver nursing care with five steps

Assessment

Involves collecting information about the person

Observation

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

Objective data

Are seen, heard, felt, or smelled by an observer

Subjective data

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

Nursing Diagnosis

Describes a health problem that can be treated by nursing measures.

Planning

Involves setting priorities and goals

Priorities

What is most important for the person

Goals

What is desired for or by the a person as a result of nursing care

Nursing intervention

An action or measure taken by the nursing team to help the person reach a goal

Nursing care plan

A written guide about the person’s nursing care

Implementation

Nursing interventions in the care plan are performed or carried out

Evaluation

Involves measuring if the goals in the planning step were met.

Reporting

Oral account of care and observations.

Recording

Written account of care and observations

End of shift report

Nurse gives a report at the end of the shift to the on-coming shift.

Anterior (ventral)

At or toward the front of the body or body part

Posterior (dorsal)

At or toward the back of the body or body part

Supine

Laying flat and facing up

prone

laying flat and facing down

lateral

lying on the side

fowler’s

laying on the back within the head of the bed raised

Root

word element that contains the basic meaning of the word