mod 15 Flashcards
(10 cards)
What is data
pieces of info
Subjective versus objective
subjective: within self a hunch, not a fact
objective: “outside of self” a piece of data or fact
oral reporting
convey info about a resident care verbally to another healthcare worker
what should a oral report include
out of limits to nrs
help ease interaction between the caregiver and resident
- resident preferences
- update on cp
- new info during shfit
What does the cp include
5-step process
support by orally reporting to nurse and charting @ end of shift
Support by following cp
Other names for charting
flow sheet
nursing assistant charting
tracking form
what is a cp
official legal doc
status of physical and emotional stat
accurate info
Incident report
a report describing a specific occurrence or incident
What to remember with charting
If it was not charting, it never happened
Med term
shortened med word
unclear ask nurse
means more than 1 meaning
prefiX: start of word
word root: main part
suffix: end of word