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  1. Communication is:
    the exchange of information
  2. For good communication (5 things):
    • Use words that mean the same thing to you and the receiver of the message.
    • Use familiar words.
    • Be brief and concise.
    • Give information in a logical and orderly manner.
    • Give facts and be specific.
  3. What 2 medical record forms will we use the most:
    • Admission sheet- RN
    • Health history- RN
    • ****Graphic sheet****
    • Progress note- RN
    • ****Flow sheets****
  4. What is a graphic sheet?
    Is used to record measurements and observations made daily, every shift, or 3-4 times a day. Includes temp, pulse, respirations, blood pressure, weight, intake, output, bowel movements, and dr visits
  5. What is a flow sheet?
    Used to record frequent measurements or observations of daily living: eating, bathing, dressing, bowel and urine...
  6. The nursing process has five steps:
    • Assessment
    • Nursing diagnosis
    • Planning
    • Implementation
    • Evaluation
  7. Objective data is also known as:
  8. Subjective data is also known as:
  9. A nursing diagnosis describes:
    a health problem that can be treated by nursing measures.
  10. Reporting is:
    the oral account of care and observations
  11. Recording is:
    (charting) the written account of care and observations.
  12. Report only:
    what you observed or did yourself
  13. A change in ________ _________ is very important to report
    Vital signs
  14. BID:
    Bi Daily (2x/day)
  15. TID
    Tri day (3x/day)
  16. QID
    Quad day (4x/day)
  17. When answering the phone say what 3 things?
    • Unit name or #
    • Your Name
    • Job Title
  18. Conflict is:
    a clash between opposing interests or ideas
  19. Who do you talk to if there is a conflict:
Card Set
chapter 4
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