Vocabulary
This occurs through the evaluation of information collected about the client through observation, reflection, and communication
What is assessment
This is a permanent and legal document required to record a client's condition, signs and symptoms of any illness, any care given and the client's response to care
What is a chart
1316hrs
What is 1:16pm
D.A.R.
What is: Data, Analysis/Action, Response
This abbreviated for means as needed or when necessary
What is PRN
This what the client feels. It is also know in the medical word as symptoms.
What is subjective information
One of the guidelines for documentation is that all entries are written in one of these ink colours. Sorry Fehnitola, no purple!
What is blue or black
2345hrs
What is 11:45pm
A.D.P.I.E.
What is: assessment, diagnosis, plan, implementation, evaluation
You client cannot have anything to eat after 2200hrs. This is the abbreviated form.
What is NPO
This is a record of the care the healthcare workers has given the client as well as observations and basic assessments made during care
What is documentation or charting
What is things only they did and saw
Midnight
What is 2400hrs or 0000hrs
P.I.E. Hmm I sure do love me some charry pie
What is: problem, intervention and evaluation
As a CCA you may be required to complete charting on a how much a client drinks and how much they eliminate. In medical terms this is known as this.
What is I&O
This is the final step in the care planning process. It involves assessing and measuring effectiveness (or not)
What is evaluation
Electronic charting is very common in some facilities. In order to protect yourself and the confidentiality of your client's, the CCA understands they must do this before leaving their laptop or iPad.
What is sign out
3:27am
0327hrs
L.P.N.
What is licensed practical nurse
The nurse has told you that she needs to check your client's BS before meals. As a CCA you know that the abbreviated form for before meals is this.
What is ac
This step in the care planning process establishes priorities and goals and developing measures or actions to help the client meet the goals
What is planning
In order to complete a charting entry, the CCA knows that he/she/they must do this at the end of an entry.
What is sign your name and designation
16 minutes after midnigh
0016hrs
C.C.A.
What is continuing care assistant
Define: Pt c/o pain to LUQ x 3 days. They are 2 days x post-op and can have Tyl. prn for pain. The OTPT wants the CCA to complete ROM on both legs q3h. Pt can amb to BR, requires help with all ADLs and likes to go to HS pc snack.
What is: patient complains of pain to the left upper quadrant of the abdomen. They had surgery two days ago. The patient can have Tylenol as needed for pain. The occupational and physical therapist would like the care aide to perform range of motion exercises on both legs every 3 hours. Patient can walk to the bathroom on their own, requires help with their activities of daily living and likes to go to bed after they eat their snack.