Easy Communication
The exchange of information between two or more persons
What is communication?
4:06 p.m.
What is 1608?
The medical record is considered this
What is a legal document?
The verbal account of care and observations
What is Reporting?
This is described as a clash between opposing interests and ideas
What is Conflict?
Communication requires these two elements
What is a receiver and a sender?
0425
What is 4:25 a.m.?
In long-term care, these three therapists often make documentation
What are PT, OT, and SLP?
A written account of care and observation
What is Recording?
Belching
Objective
When communicating with the health team, only these should be presented.
What are facts?
12:10 a.m.
What is 0010?
These nurses document the patient's ADLs
What is a nursing assistant or a certified nursing assistant?
Subjective or Objective. The patient has a black eye
What is Objective
Only these people should have access to a patient's chart
Who is anyone involved in their care?
A written account of a person's illnesses and treatment
What is a medical record?
1515
What is 3:15 p.m?
This sheet is completed when the person is admitted to the hospital or facility
What is the admission sheet?
What is Subjective?
Aside from the medical record being a legal document, it is also this.
What is a permanent record?
This is an assessment tool used in long-term care buildings
What is MDS?
12:00 a.m.
What is 0000?
A written description of the nursing care provided
What are Progress Notes?
Subjective or Objective. The nurse informs you that Mr. Jones has a pressure injury on his foot
What is Objective?
This written guide provides directions on how the patient should be cared for.