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Module Three (Chapter twenty-six)

Ethan Caliber HCA SEC V Inglés 14 fichas

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1AssessmentThe evaluation of information collected about the client through observation, reflection, and communication; a step in the care-planning process
2Care planA document that details the care and services the client must receive
3Care-Plan ProcessThe method used by nurses and case managers to plan the client's care with the health care team
4ChartA legal document that details a client's condition or illness and responses to care. Record.
5DocumentationRecord of the care the health care worker has given the client as well as the observations and basic assessments made about the client during care. Charting.
6EvaluationAssessing and measuring; a step in the care planning process
7ImplementationCarrying out or performing; a step in the care-planning process
8InterventionAn action or measure taken by the health care team to help the client meet a goal in the care plan
9Medical diagnosisThe identification of a disease or condition by a physician or nurse practitioner
10Nursing diagnosisA statement describing a health problem that is treated by nursing measures.
11PlanningEstablishing priorities and goals and developing measures or actions to help the client meet the goals; a step in the care-planning process
12SignsInformation about a client's health gained through observation and the use of other senses
13SymptomsInformation reported by a client that cannot be directly observed by others. Subjective Data
14Verbal reportA spoken account of care provided and observations made