Chapter 7 flashcards

Care plan

a document that lists a resident’s needs and goals as well as the actions and approaches the interdisciplinary team will use to help the resident achieve their goals.

Routine reporting

At the end of your shift, you will report to the charge nurse about the residents you cared for and the care you provided. Report information that is not time-sensitive and can wait until the end of the shift.

Immediate reporting

some observations must be reported immediately. You must immediately report any situation that would be considered dangerous to any resident, staff member, or visitor.

“By a certain time” reporting

This type involves information that is needed by a set time. Examples are set times for vital signs to be recorded or weights to be documented, per physician orders.