chapter 8 vocab
chapter 8 vocab
chapter 8 vocab
chapter 9 vocab
chapter 9 vocab
100

Another term for medical record is....


Chart

100

_______ is the written account of care and observations.

Recording 

100

_______ describes the care given and the persons resopnse and progress.

Progress note

100

An _____ is a shortened form of a word or phase. 

Abberviaiton 

100

A ______ is a word of element placed AFTER a root; it changes the meaning of the word. 

Suffix

200

The medical record is also called the _______.

Clilnical Record

200

Another name for objecting data is...

Signs

200

The oral account of care and observations is...

Reporting
200

A worde element palced BEFORE a root is the _____. It changes the meaning of the word. 

Prefix 

200

_____ is at or toward the back of the body or body parts; posterior. 

Dorsal

300

The legal account of a persons condition and response to treatment and care is the ____________; also reffered to as the chart or clinical record. 


Medical record 

300

_________ is to perform or carry out measures in the care plan; a step pin the nursin process. 

Implmentation

300

________ is collecting informaiton about the person; a step in the nursing process.

Nursing Diagnosis

300

At the side of the body or body parts is...

Lateral 
300

At or toward the front of the body or body parts is ventral or...

Anterior 

400

An electronic version of a person medical records is the ________ ; also called electronic medical record. 

Electronic health record (EHR)

400

Another name for an electronic health record is ________.

Electronic Medical Record (EMR)

400

A step in the nurisng porcess that is used to measure if goals in the planning step were met is called...

Evaluation

400

______ is the part farthest from the center or fffrom the point of attachment.

Distal 
400

Another word for dorsal is...

Posterior 
500

A _________ is an action or measure taken by the nursing team to help the person reach a goal.

Nursing intervention

500

__________ are things a person tells you about that you cannot observe through your senses; symtoms.

Subjective Data

500

The _______ describes a health problem that can be treated by nrusing measures; a stepin the nursing process. 

Planning

500

_____ is at or near the middle or mid-line of the body or body parts.

Medial 

500

Teh nearest to the center of the point of origin is...

Proximal