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Electronic Health Record (EHR)

A digital version of a patient's paper chart that contains the medical history, treatment plans, and other relevant patient information.

Patient Safety

Practices that reduce the risk of harm to patients during the provision of health care.

SBAR

A standardized communication framework that stands for Situation, Background, Assessment, and Recommendation, used for effective and concise verbal reports.

Assessment

The systematic process of collecting and analyzing patient data to develop a nursing diagnosis and plan of care.

Neurologic System Assessment

Evaluation of a patient's neurological function including consciousness, motor response, and the ability to communicate and swallow.

Auscultation

The act of listening to the internal sounds of a body, typically using a stethoscope as part of a physical examination.

Vital Signs (VS)

Measurements of the body’s most basic functions, including heart rate, blood pressure, respiratory rate, and temperature.

Capillary Refill

A test used to assess blood flow in peripheral tissues by measuring the time taken for color to return to an external capillary bed after pressure is applied.

Daily Weights

A consistent measure of a patient’s body weight taken daily, often used to monitor fluid status and nutritional intake.

Clinical Decision Support

Systems that provide healthcare professionals with knowledge and patient-specific information to enhance patient care.

Specialized Assessment

Targeted evaluations focusing on specific health parameters rather than a complete examination, often dictated by patient acuity.

Intensive Care Unit (ICU)

A specialized section of a hospital designed to provide intensive monitoring and care for critically ill patients.