CNA: Chapter 4

  1. chart / medical record
    a written or electronic account of a person's condition and response to treatment and care
  2. communication
    the exchange of information- a message sent is received and correctly interpreted by the intended person
  3. comprehensive care plan
    a written guide giving direction for the resident's care; required by OBRA
  4. nursing care plan
    a written guide about the person's care; care plan
  5. nursing process
    the method nurses use to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implantation, and evaluation
  6. objection data / signs
    information that is seen, heard, felt, or smelled by an observer; signs
  7. observation
    using the senses of sight, hearing, touch, and smell to collect information
  8. recording
    the written account of care and observations; charting   
  9. reporting
    the oral account of care and observations
  10. subjective data / symptoms
    things a person tells you about, that you cannot observe through your senses; symptoms
  11. MDS
    Minimum Data Set
  12. NANDA-I
    North American Nursing Diagnosis Association International
  13. OBRA
    Omnibus Budget Reconciliation Act of 1987
  14. PDA
    Personal digital assistant
  15. PHI
    Protected health information
  16. RAPs
    Resident Assessment Protocols
  17. RN
    Registered nurse
  18. admission sheet
    it has the person's identifying information
  19. health history
    completed by the nurse
  20. graphic sheet
    used to record measurements and observations made daily, every shift, or 3 to 4 times a day 
  21. progress notes
    used to describe observations, the care given, the person's response and progress
  22. flow sheets
    used to record frequent measurements or observations- person's every day activities
  23. ADL
    Activites Daily Living
Card Set
CNA: Chapter 4
everything chapter 4