Card Set Information
the exchange of information
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.
What 2 medical record forms will we use the most:
Admission sheet- RN
Health history- RN
Progress note- RN
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
What is a flow sheet?
Used to record frequent measurements or observations of daily living: eating, bathing, dressing, bowel and urine...
The nursing process has five steps:
Objective data is also known as:
Subjective data is also known as:
A nursing diagnosis describes:
a health problem that can be treated by nursing measures.
the oral account of care and observations
(charting) the written account of care and observations.
what you observed or did yourself
A change in ________ _________ is very important to report
Bi Daily (2x/day)
Tri day (3x/day)
Quad day (4x/day)
When answering the phone say what 3 things?
Unit name or #
a clash between opposing interests or ideas
Who do you talk to if there is a conflict: