2.8: II Glossary
Aphasia: A communication disorder that results from damage to portions of the brain that are responsible for language.
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…”
Bedside nurse handoff report: A handoff report in hospitals that involves patients, their family members, and both the off-going and the incoming nurses. The report is performed face to face and conducted at the patient’s bedside.
Broca’s aphasia: A type of aphasia where patients 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.
Charting by exception: 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.
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 patient problem for efficiency in documenting, as well as for reading.
Electronic Health Record (EHR): A digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.
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.
Handoff report: A process of exchanging vital patient 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.
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.
Minimum Data Set (MDS): A federally mandated assessment tool used in skilled nursing facilities to track a patient’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.
Narrative note: A type of documentation that chronicles all of the patient’s assessment findings and nursing activities that occurred throughout the shift.
Nontherapeutic responses: Responses to patients that block communication, expression of emotion, or problem-solving.
Progressive relaxation: Types of relaxation techniques that focus on reducing muscle tension and using mental imagery to induce calmness.
Relaxation breathing: A breathing technique used to reduce anxiety and control the stress response.
SOAPIE: A mnemonic for a type of documentation that is organized by six categories: Subjective, Objective, Assessment, Plan, Interventions, and Evaluation.
Therapeutic communication: The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.
Therapeutic communication techniques: Techniques that encourage patients to explore feelings, problem solve, and cope with responses to medical conditions and life events.
Verbal communication: Exchange of information using words understood by the receiver.