| A | B |
|---|
| Admission sheet | to collect information on resident/patient when they enter the nursing home or hospital |
| Progress notes | notes written by the nurse/Dr. on the progress of the resident |
| Flow Sheet | used to record ADL's; the NA would document the care given to a resident on the flow sheet. |
| observation | used the four senses to assess a client: sight, smell, touch, hearing |
| objective data | information that is gained through observation; facts |
| subjective data | information that is not necessarily factual; rather is ones personal opinion or thoughts |
| reporting | to give information orally; you would report the vital signs to the nurse. |
| recording | to write down the information on a resident in the care plan, flow sheet, or progress notes; record ADL's |
| stat | right now; right away |
| ASAP | as soon as possible |
| Care Plan | is used to identify the resident's need and how the care team will meet those needs; it also describes the diet plan; weight plan; bladder/bowel program a patient may be on |
| Diagnosis | the illness or disease; the health problem |
| confidentiality | the NA must keep patient information private |
| discharged | to be released from the hospital or nursing home: able to go home |
| baseline | the measurements/vital signs taken when a person is admitted; they will be used to compare future measurements/vital signs. |
| scale | make sure the scale is set a zero before you begin |
| legible | writing that is easy to read |
| baseline measurements | Measurements (vital signs, weight) taken at admission. Used to compare to future measurements |
