Terminology #1Terminology #1

Activities of Daily Living (ADL)Activities of Daily Living (ADL)

ObservationObservation

Medical terminologyMedical terminology

AbbreviationAbbreviation

SuffixSuffix

prefixprefix

Terminology #2Terminology #2

Root Root

Combining vowelCombining vowel

Patient care planPatient care plan

Kardex Kardex

assessmentassessment

Senses used for evaluationSenses used for evaluation

SightSight

TouchTouch

HearingHearing

SmellSmell

ABC’s of observationABC’s of observation

AppearanceAppearance

BehaviorBehavior

communicationcommunication

Objective and subjective Objective and subjective observationsobservations

Objective-signs that you see, hear, Objective-signs that you see, hear, smell (factual)smell (factual)

Subjective-what the resident tells Subjective-what the resident tells you (symptoms)you (symptoms)

Types of charting documentsTypes of charting documents

Patient record and patient chartPatient record and patient chart

KardexKardex

Nursing care planNursing care plan

Graphic chartGraphic chart

ADL sheet ADL sheet

Charting proceduresCharting procedures

Write legibly and neatlyWrite legibly and neatly

Place events in proper sequencePlace events in proper sequence

Chart for facility/policy standardsChart for facility/policy standards

Be conciseBe concise

Always use inkAlways use ink

Errors-cross out with one line, do not Errors-cross out with one line, do not eraseerase

Charting procedures #2Charting procedures #2

Include resident’s complete Include resident’s complete informationinformation

Never skip linesNever skip lines

Sign your name at end of entrySign your name at end of entry

Always date and time entriesAlways date and time entries

Chart only procedures Chart only procedures you haveyou have performedperformed

Chart only true observationsChart only true observations

Legal issues of chartingLegal issues of charting

Resident record is a legal documentResident record is a legal document

Information in chart must be kept Information in chart must be kept confidentialconfidential

Information in chart should be Information in chart should be accurate, objective, and truthfulaccurate, objective, and truthful

Word elementsWord elements

RootRoot

PrefixPrefix

SuffixSuffix

Combining wordCombining word

Abbreviation is a shortened form of Abbreviation is a shortened form of words or phrases, and are commonly words or phrases, and are commonly used in health care settingsused in health care settings