Chapter 8

care plan/ nursing care plan

a written guide about the persons nursing care

chart/medical record

legal account of a persons condition and response to treatment and care

electronic health record (EHR)/ electronic medical record EMR

electronic version of a persons medical record

end of shift report

summary of patient status and concerns at the end of a nursing shift. It ensures continuity of care and effective communication between staff.

evaluation

to measure if goals in the nurse care plan were met

implementation

to carry out nursing interventions in the care plan

nursing intervention

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

nursing process

the method nurses use to plan and deliver nursing care

progress note

describes the care given and the persons reponse and progress

recording

the written account of care and observations

subjective data/symtoms

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

objective data

things you can see with eyes smell, ect.

activites of daily living

ADL

Bowel movment

BM

care area assesment

CAA

centers for medicare and medicaid

CMS

electronic health record

EMR

EPHI

electronic protected health info

MDS

miimum data set

outcome and assesment information set

OASIS

protected health infi

PHI

Advance directives

Document stating persons wishes for end of life care

Therapy records

Records for IV, respiratory wound care ect

Consultation reports

Reports from other health care providers consulted by the patients doctor

Special consents

Signed permissions for surgeries and procedures needing informed consent

False, record everything you do

Should you only update chart if something abnormal happens?

Assignment sheet

How does a nurse communicate tasks assigned to you