Term
| t/f enter date and time with each entry |
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Definition
|
|
Term
|
Definition
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|
Term
| t/f always document your opinion |
|
Definition
| FALSE: factual info only! |
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Term
|
Definition
subjective
objective
assess
plan
intervention
evaluation
revision |
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Term
|
Definition
problem
intervention
evaluation |
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Term
|
Definition
| only exceptions to norms are documented |
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Term
| purpose of computerised documentation |
|
Definition
large volumes of information
error reduction
accessibility |
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Term
| physical change and increase in size; includes height, weight, bone size and dentition (teeth) |
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Definition
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Term
| increase in complexity of function and skill progression; capacity to adapt to an environment |
|
Definition
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Term
|
Definition
| birth to day 28; follows objects, closes hands (reflex) |
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Term
|
Definition
| one month to 1 year; sits, crawls, stands |
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Term
|
Definition
| 1-3 years; skill with utensils, has daytime bowel/bladder control |
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Term
|
Definition
| 3-6 years; climbs, learns letters/numbers, 1000 word vocabulary |
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Term
|
Definition
| 6-12 years; participates in group activities, accomplishes tasks |
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Term
|
Definition
| 12-20 years; puberty, peers and independence are important, take risks |
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Term
|
Definition
| 20-40 years; finds life path, establishes long-term relationships |
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Term
|
Definition
| 40-65 years; establishes career, commitment to family |
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Term
|
Definition
| "young old" 65-74 years; retirement or semi retirement, new activities |
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Term
|
Definition
| 75-84 years; adapts to physical and sensory changes |
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Term
|
Definition
| 85 years and older; assistive devices may be needed, may need help with ADLs |
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Term
| two most common responses to hospital admission |
|
Definition
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|
Term
|
Definition
| surrender of belongings, privacy, and independence |
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Term
| t/f always address patient by last name unless they say you can call them something else and it has been documented |
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Definition
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|
Term
|
Definition
| HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT |
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Term
|
Definition
patient request
condition change |
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Term
| official procedure by which the patient leaves the health care facility for home or other setting |
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Definition
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|
Term
| patient leaving medical facility without permission of primary care provider |
|
Definition
| AMA against medical advice |
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Term
| the exchange of information or thoughts between two or more people |
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Definition
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|
Term
| feedback that both parties understand the message in the same manner |
|
Definition
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|
Term
| distance people prefer in interactions with others |
|
Definition
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|
Term
| study of spatial distances between individuals in different cultures and situations |
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Definition
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|
Term
| space or things patients consider theirs |
|
Definition
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|
Term
| exchange of ideas using spoken or writtenword to include electronic communication |
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Definition
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|
Term
| gestures, facial expression, and touch |
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Definition
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|
Term
| __-__% of communication is nonverbal |
|
Definition
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|
Term
| patient centered, goal-directed, time-limited communication; used to determine patients' concerns, problems, feelings, or progress |
|
Definition
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|
Term
| loss of ability to speak or understand written or verbal language |
|
Definition
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|
Term
| difficulty articulation words, often a result of stroke |
|
Definition
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|
Term
|
Definition
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|
Term
| seeking to gain specific information in an interview; closed ended questions |
|
Definition
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|
Term
| interview where the patient controls the conversation; open ended statements/questions |
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Definition
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|
Term
| 3 theories of human learning |
|
Definition
behaviorism
cognitivism
humanism |
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|
Term
| learning where environment influences behavior |
|
Definition
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|
Term
| learning as a complex thinking process |
|
Definition
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|
Term
| learning focused on self-development |
|
Definition
|
|
Term
| inhibiting factors of patient learning |
|
Definition
| emotions, learning plateau, physiological event, terminology |
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