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NF 2.02 Terms

AB
ReportingThe verbal sharing of resident/patient information.
RecordingThe writing of resident/patient information. It also refers to entering resident data in an electronic charting system. Recording is often referred to as charting or documenting.
ConciseExpressing much in few words.
Military Time24-hour clock. The hours are numbered from 0000 or 2400 through 2300.
Incident ReportA concise objective report of an unexpected event. The purpose is to collect information about what happened. The purpose is not to assign blame.
Body LanguageThis is one form of non-verbal communication and it sends messages just like words do.
Resident Care PlanAn individualized plan for each resident. It is developed to help achieve goals of care. This plan list tasks that each member of the care team must perform.
Resident Medical RecordA permanent, confidential, and legal collection of medical information that includes assessments, implementations, evaluations, management plans, and progress notes.
CareTrackerOne example of a computer program designed to make it easy for nurse aides and other staff to accurately document resident care.
ADLActivities of Daily Living. ADLs include bathing, dressing, caring for teeth, skin, nails, and hair, walking, transferring, toileting, and eating and drinking.
abdabdomen
ac, ACBefore meals
ad libAs desired
ambAmbulatory, able to walk
bidTwo times a day
BMBowel Movement
BP or B/PBlood Pressure
STATAt once, immediately
w/cWheelchair
c/oComplains of
CHFCongestive heart failure
DNRDo Not Resuscitate
Dx or dxDiagnosis – what is wrong with the resident, what illness
FBSFasting blood sugar
FWBFull weight bearing
HSHour of sleep, bedtime
incIncontinent
NPONothing by mouth
NWBNon weight bearing
OOBOut of bed
TIDThree times a day
pcAfter meals
PRN or prnAs necessary


Jimmy C. Draughn High School
Valdese, NC

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