Chapter 7 Flashcards
Health Team Communications
medical record (chart)
legal account of person’s care done / plan / doctors orders and medical health history
electronic health / medical record (EHR / EMR)
electronic medical record (chart)
the nursing process
method to plan / deliver nursing care
nursing care plan
written guide about person’s nursing care
nursing intervention
actions / measures to help reach person’s goal
nursing process steps
1) assessment
2) diagnosis
3) planning
4) implementation
5) evaluation
1) assessment
collecting info on person’s condition / history for care
2) diagnosis
describe health problems treated with nursing measures
3) planning
setting priorities / goals of person’s care
4) implementation
where action in care plan performed / carried out
5) evaluation
measuring if goal plans were met
observations
collecting info using 5 senses
objective data (signs)
seen, smelt, felt, heard observations of patient (bruises, bleeding, coughing, etc.)
subjective data (symptoms)
things that are not able to be seen with human senses alone (patient feelings / pain level, heart rate, etc.)
reporting
oral account of care and observations
