| A | B |
|---|
| medical record | Patient's chart. Contains all orders, tests, treatments, and care during that time. |
| documentation | Means "charing". If the nurse doesn't document, the care didn't happen in the court of law. |
| source-oriented charting | Focuses on the patient's disease. Known as narrative charting. |
| problem-oriented charting | Focuses on the problems experienced by the patient as a result of being ill. |
| focus charting | Centers aroundthe patient with a positive perspective. |
| pie charting | Charts by problem, interventions, and evaluation. |
| charting by exception | Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented. Documenting only the abnormal findings. |
| 2145 | 9:45 p.m. |
| 0756 | 7:56 a.m. |
| nonverbal communication ques | anxiety, fear, pain can be expressed this way. |
| therapeutic communication | Focussed on the needs of the patient and promotes understanding between the sender and the receiver. |
| open-ended questions | Requires an answer of more than one word or two. To share thoughts and feelings. |
| restating | Used to encourage the patient to continue with inofrmation on a topic. Uses different words for same thought. |
| giving advice | places focus on nurse instead of patient. Not therapeutic, do not practice. |
| rapport | trusting relationship |
| empathy | ability to understand by seeing the situation from another's perspective. |
| hope | What helps a patient cope in a difficult situation. |
| aphasia | difficulty expressing or understanding language. |
| physician orders | Must be taken verbally, written by licensed nurses. Student nurses can not legally take orders. |
| discharge planning/teaching | A process that begins at the time of a patient's admission. |
| kinesthetic learning | Learns by actually doing, "hands on". |
| affective domain | the learner's beliefs, feelings, and values. |
| return demonstration | Patient demonstrates skill learned. |
