Communicating with the Health Team

Communication

The exchange of information between health team members to give coordinated and effective care.

Medical Record (Chart)

A written or electronic account of a person's condition, treatment, and care that is permanent and can be used as legal evidence. Each page has the person's name, room and bed numbers, and other identifying information

Kardex

A type of card file that summarizes a person's drugs, treatments, diagnoses, care measures, equipment, and special needs.

Nursing Process

The method nurses use to plan and deliver nursing care, consisting of five steps: assessment, nursing diagnosis, planning, implementation, and evaluation.

Assessment

The first step of the nursing process involving collecting information about the person through health history, medical records, and observations.

Nursing Diagnosis

A description of a health problem that can be treated by nursing measures, made by the RN using assessment information.

Planning

The step of the nursing process involving setting priorities, goals, and developing a nursing care plan.

OBRA requires two types of resident care conferences:

Interdisciplinary care planning (IDCP) conference, Problem-focused conference

Implementation

The step of the nursing process that involves performing the nursing measures and tasks outlined in the care plan.

Evaluation

The step of the nursing process that involves measuring whether the goals in the planning step were met.

OBRA Requirement for Nursing Centers

The Minimum Data Set (MDS) and a comprehensive care plan required for nursing center residents.

Reporting vs. Recording

Reporting is the oral account of care and observations; recording (charting) is the written account.

Root (Medical Terminology)

The word element that contains the basic meaning of a medical term.

Prefix

A word element placed before a root in medical terminology.

Suffix

A word element placed after a root in medical terminology.

Proximal

The part of the body nearest to the center or to the point of origin.

Posterior

(ventral): At or toward the front of the body or body part

Anterior

(dorsal): At or toward the back of the body or body part

Distal

The part of the body farthest from the center or from the point of attachment.

Lateral

Away from the midline; at the side of the body or body part.

Medial

At or near the middle or midline of the body or body part.

Protected Health Information (PHI)

Information that must be kept confidential when using computers and electronic devices in healthcare.

Problem-Solving Process for Conflict

A 6-step process: define the problem, collect information, identify solutions, select the best solution, carry out the solution, and evaluate results.

Agencies have policies about medical records that address:

Who can see them, Who records, When to record, Abbreviations, How to make entries, Correcting errors

The Omnibus Budget Reconciliation Act of 1987(OBRA) requires

the Minimum Data Set (MDS) for nursing center residents.