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Foundation of Nursing 1 Terms > Communication & Documentation > Flashcards

Communication & Documentation Flashcards

1
Q

aggressive behavior

A

standing up for one’s rights in a negative manner that violates the rights of others

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2
Q

assertive behavior

A

standing up for oneself and others using open, honest, and direct communication

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3
Q

CUS tool

A

communication related to patient safety concerns. concerned uncomfortable safety issue

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4
Q

empathy

A

understanding how the patient feels

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5
Q

horizontal violence

A

anger and aggressive behavior between nurses

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6
Q

incivility

A

rude, intimidating behavior directed at another person

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7
Q

intERpersonal communication

A

occurs between 2 or more people, exchanges messages

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8
Q

intRApersonal communication

A

self-talk to enhance positive interaction with patient and family

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9
Q

organizational communication

A

involves individuals and groups to achieve established goals

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10
Q

rapport

A

mutual trust experienced by people in a satisfactory relationship

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11
Q

SBAR tool

A

communication between healthcare personnel. Situation, background, assessment, recommendations

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12
Q

small-group communication

A

occurs when 2 or more nurses interact with 2 or more individuals

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13
Q

Bedside report

A

Standardized shift report at the bedside , helps ensure safe handoff of care between nurses

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14
Q

Change of shift report

A

Used to transmit patient information to nurses who continue the care

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15
Q

Charting by exception (CBE)

A

Documenting patient data only when it is does not match the standard

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16
Q

Confer

A

Consult with someone, exchange of ideas or seeking information or advice

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17
Q

Consultation

A

Two or more individuals with varying experience process a problem and its solution

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18
Q

Critical or Collaborative pathway

A

Detailed, standardized plan of care developed for a population with a diagnosis or procedure. Has expected outcomes and interventions

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19
Q

Discharge summary

A

Describes patient and their relation to problems. Can give special teaching, referrals, or counseling

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20
Q

Documentation includes

A

Assessments, diagnoses, plans, interventions, and evaluations

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21
Q

Electronic Health record (EHR)

A

Contains medical history, diagnoses, medications, treatment plans, immunization dates, allergies, lab results

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22
Q

Flow sheet

A

Graphic record of aspects of a patient’s condition

23
Q

Focus charting

A

Focus column that includes aspects of a patient and patient care. Uses DAR. Data, action, response

24
Q

Handoff

A

Nurse’s report to another nurse about patient status and progress

25
Q

Health Information Exchange (HIE)

A

Allows healthcare providers and patients to access a patient’s medical info

26
Q

Incident or variance report

A

Any event that is not valid with a Healthcare facility. Has potential to harm

27
Q

ISBAR communication

A

Handoff communication among Healthcare providers about patients condition. Identity/introduction, situation, background, assessment, recommendation/read back

28
Q

Minimum data set

A

The information that must be collected from every patient

29
Q

Narrative notes

A

Progress notes written in a source oriented record

30
Q

Occurrence or variance charting

A

When a patient fails to meet an expected outcome. Includes cause and actions taken in response

31
Q

Outcome and Assessment Information Set (OASIS)

A

Assessment instrument, core items of a comprehensive assessment for adult home health care patients. Measures patient outcomes for improving quality of care

32
Q

Patient record

A

Compilation of patients health info. Details nurse’s interactions

33
Q

Personal health record (PHR)

A

Information sheets including medical history, including diagnoses, symptoms, and medications

34
Q

PIE charting

A

Incorporated into progress notes, problems are identified by number. Problem, intervention, evaluation

35
Q

Problem oriented medical record (POMR)

A

Organized according to the specific health problems, includes problem list, plan of care and progress notes

36
Q

Progress notes

A

Any method of note that relates to how a patient is progressing

37
Q

Purposeful rounding

A

Nurse driven, evidence based intervention that helps nurses anticipate and address patient needs

38
Q

Read back

A

Repeating a verbal order to ensure it was heard correctly

39
Q

SOAP Format

A

Charting narrative progress notes. Subjective information, objective information, assessment, plan

40
Q

Source oriented record

A

Each heathcare group records data on its own separate form

41
Q

bullying

A

negative, repetitive and disruptive behavior

42
Q

bullying is also referred to __ violence (2 types)

A

horizontal and lateral

43
Q

channel

A

a term used to represent the way a message is conveyed/given, can target any receiver’s senses (see communication theory)

44
Q

communication

A

process of sharing information and transmitting meanings

45
Q

cliché

A

a stereotyped answer

46
Q

feedback

A

verbal and nonverbal evidence that the message is received and understood

47
Q

group dynamics

A

study of a group’s (population of people) characteristics and ways of functioning

48
Q

helping relationship

A

interaction that sets the pace towards common goals for the patient or participants

49
Q

language

A

prescribed way of using words, a way to express feelings and thoughts

50
Q

message

A

a term used to describe the physical product of the source, a speech or phone call (see communication theory)

51
Q

noise

A

factors the distort the quality of a message, interferes with communication process

52
Q

semantics

A

study of the meaning of words

53
Q

graphic record

A

form used to record specific patient variables

54
Q

referral

A

process of sending or guiding someone to another source for assistance

Foundation of Nursing 1 Terms (16 decks)

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