Communication and Informatics Vocabulary Flashcards

A complete set of vocabulary flashcards derived from Potter & Perry (Chapters 24 & 26) and Giddens (Concepts 44 & 48) covering key terms in nursing communication, documentation, electronic records, patient privacy, and health informatics.

Communication

A process of interaction between people in which symbols are used to create, exchange, and interpret messages about ideas, emotions, and mind states.

Verbal Communication

Spoken words or written symbols used in communication.

Nonverbal Communication

All communication that is not spoken or written, such as gestures, eye contact, and facial expressions.

ISBAR-R

An effective communication technique standing for Identify, Situation, Background, Assessment, Recommendation, and Readback.

Therapeutic Communication

Communication that occurs within a healing relationship between a nurse and patient.

Communication Competence

Nursing communication that is effective and appropriate, encompassing skills for communicating clearly and accurately with patients, families, and healthcare team members.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Laws and regulations that address patient privacy and consent for the use of identifiable personal health information.

Protected Health Information (PHI)

Identifiable personal health information that is safeguarded using privacy, confidentiality, and security mechanisms such as firewalls and passwords.

Electronic Health Record (EHR)

An individual's lifetime computerized health record.

Electronic Medical Record (EMR)

The record for an individual health care visit.

Documentation

A key communication strategy that produces a written account of patient data, clinical intervention, and patient responses.

Incidence or Occurrence Reports

Reports used to document unique events or incidents that are NOT part of the medical record.

OASIS

One of two data sets used by nurses to document clinical assessments and care provided in the home care setting.

Omaha System

One of two data sets used by nurses to document clinical assessments and care provided in the home care setting.

Connected Health

An approach that allows for broad-based health information exchange to improve quality, safety, and efficiency in health care.

Technology

The knowledge and use of tools, machines, materials, and processes to help solve human problems.

Informatics

The science that encompasses information science and computer science to study the process, management, and retrieval of information.

Health Informatics

A discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology.

Nursing Informatics

A specialty area of practice that integrates nursing science, computer science, and information science.