II Glossary
Open Resources for Nursing (Open RN)
Active listening: Process by which we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. (Chapter 2.3)
Aphasia: A communication disorder that results from damage to portions of the brain that are responsible for language. (Chapter 2.3)
Assertive communication: A way to convey information that describes the facts, the sender’s feelings, and explanations without disrespecting the receiver’s feelings. This communication is often described as using “I” messages: “I feel…,” “I understand…,” or “Help me to understand…” (Chapter 2.2)
Bedside handoff report: A handoff report in hospitals that involves clients, their family members, and both the off-going and the incoming nurses. The report is performed face to face and conducted at the client’s bedside. (Chapter 2.4)
Broca’s aphasia: A type of aphasia where clients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca’s aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated. (Chapter 2.3)
Charting by exception (CBE): A type of documentation where a list of “normal findings” is provided and nurses document assessment findings by confirming normal findings and writing brief documentation notes for any abnormal findings. (Chapter 2.5)
DAR: A type of documentation often used in combination with charting by exception. DAR stands for Data, Action, and Response. Focused DAR notes are brief, and each note is focused on one client problem for efficiency in documenting, as well as for reading. (Chapter 2.5)
Electronic Health Record (EHR): A digital version of a client’s paper chart. EHRs are real-time, client-centered records that make information available instantly and securely to authorized users. (Chapter 2.5)
Expressive aphasia: A type of aphasia where the client has difficulty putting thoughts into words. The client may cognitively know what they want to say but are unable to express their thoughts. (Chapter 1.4, Chapter 2.3)
Global aphasia: A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences. (Chapter 2.3)
Handoff report: A process of exchanging vital client information, responsibility, and accountability between the off-going and incoming nurses in an effort to ensure safe continuity of care and the delivery of best clinical practices. (Chapter 2.4)
Health Insurance Portability and Accountability Act (HIPAA): Standards for ensuring privacy of client information that are enforceable by law. (Chapter 2.3)
Incident reports: Also called variance reports, incident reports are a specific type of documentation that is completed when there is an unexpected occurrence, such as a medication error, client injury, or client fall, or a near miss, where an error did not actually occur, but was prevented from occurring. (Chapter 2.5)
ISBARR: A mnemonic for the format of professional communication among health care team members that includes Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back. (Chapter 2.4)
Minimum Data Set (MDS): A federally mandated assessment tool used in skilled nursing facilities to track a client’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life. (Chapter 2.5)
Narrative note: A type of documentation that chronicles all of the client’s assessment findings and nursing activities that occurred throughout the shift. (Chapter 2.5)
Nontherapeutic responses: Responses to clients that block communication, expression of emotion, or problem-solving. (Chapter 2.3)
Nonverbal communication: Facial expressions, tone of voice, pace of the conversation, and body language. (Chapter 2.2)
Progressive relaxation: Types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness. (Chapter 2.2)
Receptive aphasia: A type of aphasia where the client has difficulty in understanding what is being communicated to them. The client may be able to verbalize their thoughts and feelings but does not understand what is spoken to them. (Chapter 2.3)
Relaxation breathing: A breathing technique used to reduce anxiety and control the stress response. (Chapter 2.2)
SOAPIE: A mnemonic for a type of documentation that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. (Chapter 2.5)
Therapeutic communication: The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to client understanding and participation. (Chapter 2.3)
Therapeutic communication techniques: Techniques that encourage clients to explore feelings, problem solve, and cope with responses to medical conditions and life events. (Chapter 2.3)
Verbal communication: Exchange of information using words understood by the receiver. (Chapter 2.2)