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CH 8 Observe/Report/Document

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Across
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Nursing plan for care of a resident in a long-term care facility
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Electronic medical record- digital patient record fora single organization or setting
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Observation based on ideas perceived only by the individual involved
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Noticing something
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Putting into effect
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Statement of a patients problems leading to nursing interventions
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Standard structure for concise, factual, effective and meaning reporting of patient information.
Down
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Observation made through the senses of the observer
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Framework for nursing action
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Verbal report
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Actions that influence that eventual outcome of a situation
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Electronic health record-patient record in digital format, not complete medical record
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Law passed in 1996 protect privacy, confidentiality, medical records, and other individually identifiable patient information