Vocab (10)
Form of written communication and serves as a permanent record of patient information and care provided by all members of the healthcare team
What is documentation?
Regulates all areas of information management, including reimbursement, coding, and security of records
What is HIPAA?
Documents medication administration
What is MAR or EMAR?
Supports the patient’s right to the information necessary to make his or her own decisions about treatment options and nursing care
What is Advocacy?
Qualities known only
to the individual
What is the hidden panel?
Form of verbal communication and takes place when two or more people share information about patient care
What is reporting?
To document only those findings that fall outside the standard of care and norms that have been defined by the institution
What is charting by exception?
Any unusual happening, such as a fall, medication error, malfunction in equipment, or injury to a patient, visitor, or employee, that occurs during the performance of healthcare activities.
What is incident report?
The ability to look at things from another’s perspective and to be able to share the essence of that understanding through verbal and nonverbal communication
What is empathy?
The “mask” exhibited
to others
What is the open panel?
Means to collect, store, and share patient data electronically so that it may be analyzed and used to improve outcomes
What is electronic health record?
A progress note that relates to only one health problem.
What is "SOAP?"
When a provider calls out an order, the nurse will loudly and clearly repeating the order.
What is a checkback or repeat and verification?
Refers to warmth, caring, interest, and respect for the person, seeing the person unconditionally or nonjudgmentally
What is positive regard?
Qualities not
recognized by the individual, but are
noticed and known by others
What is the blind panel?
Serious reportable events
What are "never events?"
Generated at admission and revised to reflect changes in the patient’s condition
What is plan of care?
When a specialist or health team member must provide an expert opinion or specialized care for a patient
What is a consult?
Communicator or source of information
Who is a sender?
Opening remarks
Active listening
What is therapeutic communication?
Interfaces medication orders with pharmacy dispensing and allows direct computer charting of medication administration.
What is eMAR?
Transfer of care for a patient from one health provider to another, significantly increasing the risk of errors.
What is handoff?
When a Physician sees a patient and the nurse attends, so that the nurse can inform about any current medical problems or help reinforce information to patient.
What is rounding?
The one who is given communication
Who is the receiver?
False reassurance
Giving advice
What is nontherapeutic communication?