Fundamentals of Nursing: Key Terms- Chapter 16 Flashcards


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1

change of shift reports

communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped

2

charting by exception (CBE)

shorthand method for documenting patient data that is based on well defined standards or practice;
only exceptions to these standards are documented in narrative notes

3

collaborative pathway

case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnoses or procedure;

it includes expected outcomes, a lost of interventions to be performed, and the sequence and timing of those interventions

4

confer

to consult with someone to exchange ideas or to seek info, advice, or instructions

5

consultation

process in which 2 or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

6

discharge summary

description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals

7

documentation

written, legal record of all pertinent interventions with the patient - assessments, diagnoses, plans, interventions, and evaluations

8

flow sheet

graphic record of abbreviated aspects of the patients condition

(vital signs, routine aspects of care)

9

focus charting

a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format

10

hand off

a nurses report to another nurse or health care provider about a patients status and progress

11

Health Information Exchange

HIE

an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information

12

ISBAR communcation

a process for effective hand-off communication among health care professionals about a patient’s condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back

13

meaningful use

the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from medicare and medicaid

14

minimum data set

a standard established by health care institutions that specifies the information that must be collected from every patient

15

narrative notes

progress notes written by nurses in a source oriented record

16

nursing informatics

specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

17

patient record

a compilation of a patients health information;

the patient record is the only permanent legal document that details the nurses interaction with the patient

18

personal health record

PHR

information sheets that contain the individuals medical history, including diagnoses, symptoms, and medications.

19

PIE charting

documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)–intervention (I)–evaluation (E) format, and evaluated each shift

20

problem oriented medical record

POMR

documentation system organized according to the persons specific health problems;
includes database, problem list, plan of care, and progress notes

21

progress notes

any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes

22

read back

a process in which a nurse or other heath care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted

23

referral

process of sending or guiding someone to another source for assistance

24

SOAP format

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

25

source oriented record

documentation system in which each health care group records data on its own separate form

26

variance report

a report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor.