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Using the senses of sight, hearing, touch, and smell to collect information.
Observation
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This type of data is seen, heard, felt, or smelled.
Objective data (signs) You can feel a pulse. You can see urine. You cannot feel or see the person's pain, fear, or nausea.
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Things a person tells you about that you cannot observe thrugh your senses.
Subjective data (symptoms)
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The health team communicates by reporting and recording. Both are accounts of what was done for and observed about the person.
- Reporting is the oral account of care and observations.
- Recording (charting) is the written account of care and observations.
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Rules for Recording:
- Always use ink
- Never erase errors or use correction fluid. Cross out the incorrect part, and write "error" or "mistaken
entry" over it. Sign your initials to the error or mistaken entry. Then rewrithe the part.
- Do not skip lines. Draw a line through the blank space of a partially completed line or to the end of a
page. This prevents others from recording in a space with your signature.
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Military time or international time:
The hour is the same for morning times, but AM is not used. For PM times, add 12 to the clock time.
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Do not use e-mail for informaionn or messages that requiere immediate reporting. Give the report in person (The person may not read e-mail in a timely manner)
Do not use e-mail or messages to report confidential information.
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A word element placed before a root.
Prefix
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Contains the word's basic meaning.
Root. It's combined with another root, with prefixes, and with suffixes.
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Placed after a root. It changes the meaning of a word.
- suffix. When translating medical terms, begin with the suffix.
- For example, nephritis means inflammation of the kidney. It was formed by combining nephro (kidney) and itis (inflamation).
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At or toward the front of the body or body part.
Anterior (ventral)
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The part farthest from the center or from the point of attachment.
Distal
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At the side of the body or body part.
Lateral
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At or near the middle or midline of the body or body part.
Medial
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At or toward the back of the body or body part.
Posterior (dorsal)
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The part nearest to the center or to the point of origin.
Proximal
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