unit 15 - cna sisu

HIPAA

Health Insurance Portability and Accountability Act

EKG/ECG

Electrocardiogram

GI

gastrointestinal

GU

genitourinary

NG

nasogastric (nose to stomach)

OG

orogastric (mouth to stomach)

prn

as needed

STAT

immediately

ROM

range of motion

CHF

congestive heart failure

CVA

cerebrovascular accident (stroke)

RACE

Rescue, Alarm, Confine or Contain, Extinguish or Evacuate

SCD

sequential compression device

abnormal

Deviating from what is considered typical or usual; not within normal parameters.

diagnosis

The identification or determination of a person's medical condition or illness based on symptoms, signs, and diagnostic tests.

EHR

electronic health record or the patient chart

Minimum Data Set (MDS)

A standardized assessment tool used in long-term care facilities to collect essential data on resident health status, functioning, and care needs for care planning and quality monitoring purposes.

objective

Observable and measurable data or information obtained through direct observation, examination, or testing, free from personal bias or interpretation.

subjective

Information or data based on personal opinions, interpretations, feelings, or experiences, often provided by the patient or caregiver and influenced by individual perceptions and biases.

root

The basic or fundamental part of a word that carries its primary meaning and forms the basis for creating related words with prefixes and suffixes.

prefix

A word element placed before a root or base word to modify its meaning or create a new word.

suffix

A word element placed after a root or base word to modify its meaning or create a new word.

Resident Assessment Instrument (RAI)

A comprehensive assessment tool used in nursing homes to evaluate residents' physical, cognitive, and psychosocial functioning, determine care needs, and develop individualized care plans.

progress note

Documentation entries made by healthcare professionals to record a patient's progress, response to treatment, changes in condition, and other pertinent information during their hospital stay or outpatient visits.