Flashcards
Module Three (Chapter twenty-six)
Cards in this deck (14)
- 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