Communicating
Observations
With the Team
Chart Parts
General & Military
100
The exchange of information
What is communication?
100
Something that you notice about the patient or resident, typically related to a change in the person's physical or mental condition
What is observations?
100
The spoken exchange of information
What is reporting?
100
Lists the person's previous surgical and medical conditions, current medications, allergies, and current medications and allergies and current diagnosis
What is the medical history?
100
Discord resulting from differences between people; can occur when one person is unable to understand or accept another's ideas or beliefs
What is conflict?
200
A way of communication that uses written, spoken or sign language
What is verbal communication?
200
Information that is obtained directly through measurements of by using one of the five senses (sight, smell, taste, hearing, or touch.)
What is objective data?
200
Communicating information about a patient or resident to other team members in written form, sometimes called charting or documenting.
What is recording?
200
Used to order diagnostic tests and treatments and to specify dietary orders or activity orders
What is physician's order sheet?
200
-Ask to speak privately -Focus on specific areas of conflict -Be specific about what you understand the problem to be -Be prepared to hear how the other person may feel toward you -Be gracious enough to apologize for misunderstanding the other person -Ask the other person for ideas about how to resolve the conflict -Sometimes agree to disagree
What are steps to resolve a conflict?
300
A way of communicating that uses facial expression, gestures and body language, instead of written or spoken language
What is nonverbal communication?
300
Information that cannot be objectively measure or assessed
What is Subjective Data?
300
A legal document where information about a patient's or resident's current condition, the measures that have been taken by the medical and nursing staff to diagnose and treat the condition and the patient's or residents response to the treatment and care provided.
What is a medical record?
300
Lists medications ordered for the patient or resident, route to be administered, and times to be given.
What is MAR or medication administration record?
300
1445
What is 2:45 pm in military time?
400
Often useful when trying to communicate on a basic level when someone speaks a different language, is hearing impaired or has developmental disabilities
What is a picture board?
400
Objective evidence of disease, based on data that are obtained directly through measurements or by using one of the five senses
What is Signs?
400
A card file that contains condensed versions of each patient's or resident's medical record
What is a kardex?
400
Contains observations (signs and symptoms) noted by the physician about the person's response to treatment.
What is the physician's progress notes?
400
0215
What is 2:15 am in military time?
500
When trying to communicate with this disability, speak slowly, in a lower pitch and always face the person.
What is hard of hearing?
500
Subjective evidence of disease, based on information that cannot be measured or observed first hand, such as a patient's or resident's complaint of pain
What are symptoms?
500
-Write legibly using dark blue or black ink -Always sign or initial your entry, according to facility policy -Only record observations that you havemade or care that you have given -Date and time your entries correctly -Use appropriate medical terminology -Record information in a timely manner -If you make an error, do not erase or use correction fluid or scribble through the mistaken entry. Simply draw a line through it and initial and time it.
What are the guidelines for recording?
500
Contains information gathered routinely such as vital signs, the frequency of urination an bowel movement and the food and fluid intake.
What is the graphic sheet?
500
2130
What is 9:30 pm in military time?
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