Clinical Practice and Documentation Vocabulary

Vocabulary terms covering documentation methods, physiological responses to straining, and biomechanical principles of patient care.

Charting by exception

A practice where everything is documented as normal unless there is a deviation or abnormality.

Deviation

An abnormality or change from the normal status that requires documentation.

Strain (constipation)

A physical effort during bowel movements that can lead to a decreased heart rate and decreased blood pressure.

Unaffected side

The side of the body that should be held or supported during movement or care.

Base of support

Maintaining a wide stance with the feet to ensure stability when lifting.

Biomechanics

The study of mechanical laws relating to the movement or structure of living organisms, particularly regarding gait and lifting.

Delegation

A focus area for study involving the assignment of tasks to other team members.