Nursing Shift Reports, SBAR, and Informatics Essentials

Vocabulary flashcards covering bedside reporting, SBAR, telephone orders, informatics, telehealth, patient education, interpreters, and communication strategies as discussed in the lecture notes.

Bedside shift report

A shift handover conducted at the patient’s bedside that involves the patient in the report and uses a concise format (often SBAR) to organize information.

Privacy

Concerns about protecting patient information during reports (e.g., recordings or bedside exchanges); may require protections like password-protected access.

SBAR

A concise communication framework: Situation, Background, Assessment, Recommendation, used to convey patient issues to physicians and other nurses.

Readback

Repeating back a physician’s orders or critical information to verify accuracy, including confirming date/time and spelling.

Telephone order

A clinician’s patient-care order given by phone; must be documented, read back, and ideally issued by the physician; students cannot place orders.

Care plan conference

A multidisciplinary meeting (physician, nurses, pharmacy, social workers, etc.) to discuss patient care, discharge planning, medications, and symptoms, often with a respectful, nonjudgmental approach.

Biomedical informatics

The interdisciplinary science that integrates nursing, computer science, information management, and analytics to improve healthcare information use.

Electronic Health Record (EHR)

A digital, integrated, real-time patient record used across disciplines to support order management, decision-making, and quality monitoring.

Electronic Medical Record (EMR)

A digital version of a patient’s chart within a single organization; a precursor/related concept to the EHR with domain-specific uses.

Point of care testing

Laboratory testing conducted at the time and place of patient care with results automatically recorded in the chart.

HIPAA

Health Insurance Portability and Accountability Act; 1996 law protecting patient privacy and security of health information.

Telehealth

Delivery of health care via telecommunications technologies to increase access, not a full replacement for in-person care.

MyUPMC

A patient portal that provides access to records, test results, discharge instructions, and educational materials.

GPS in health care

Use of geographic data to analyze public health trends, inform policy, and understand health patterns by location.

Patient education materials

Printed or digital instructions and information (e.g., discharge instructions, meds, lab results) provided to patients.

Interpreters

Language services (in-person, telephone, or video) used to facilitate communication with patients who have limited English proficiency.

Visual impairment communication strategies

Techniques for communicating with patients who have vision deficits: narrate actions, use a well-lit environment, use large print or glasses, and position yourself clearly.

Hearing impairment communication strategies

Strategies for patients with hearing loss: use hearing aids, reduce background noise, speak slowly and clearly, and consider teach-back and interpreters.

Teach-back method

Asking a patient to explain in their own words how they will follow instructions to confirm understanding.

Charting vs patient safety

The patient’s care comes first; charting should reflect reality, not replace sound nursing judgment or delayed care due to documentation.