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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
- ****Graphic sheet****
- Progress note- RN
- ****Flow sheets****
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:
- Nursing diagnosis
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
When answering the phone say what 3 things?
- Unit name or #
- Your Name
- Job Title
a clash between opposing interests or ideas
Who do you talk to if there is a conflict: