| auditors | people appointed to examine patient charts and health records to assess quality of care |
| chart(health care record) | a legal record that is used to meet the many demands of the health, accreditation, medical insurance and legal systems |
| charting | process of recording information on a patient's chart |
| charting recording or documenting | process of noting data in a patient record , usually as prescribed intervals |
| charting by exception | recording only new data or changes in a patient status or care; charting the exceptions to the previously recorded data |
| computer on wheels (COWs) | POC systems are sometimes housed on wheeled carts |
| database | from the history, the physical examination and the diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists |
| diagnosis related groups (DRGs) | how hospitals get paid, cost reimbursement rates by government plans |
| documenting | involves recording the interventions carried out to meet the patient's needs |
| electronic health record (EHRs) | allows exchange of patient data not only within a facility but also from one facility to another |
| electronic medical record (EMRs) | also referred as (EHRs) |
| informatics | the study of information processing |
| Kardex (or RAND) | system used by some facilities to consolidate patient orders and care needs in a centralized, concise way |
| narrative charting | recording of patient care n descriptive form |
| nomenclature | a classified system of technical or scientific names and terminology |
| nursing care plan | outlines the proposed nursing care based on the nursing care based on the nursing assessment and the identified patient problems to prove contimtusi |
| nursing notes | form on the patient's chart on which nursed record observations, the care given |
| peer review | an appraisal by professional coworkers of equal status |
| personal health record (PHR) | an extension of the EHR that allows patients to input their information into an electronic database |
| point of care (POC) | systems permit computer input only at the nurses' station; some facilities have bedside systems |
| problem list | active, inactive, potential, and resolved problems serve as the index for chart documentation |
| quality assurance, assessment, and improvement | an audit in health care that evaluates services provided and the results achieved compared with accepted standards |
| recording | process of adding written information to the chart, usually at prescribed intervals |
| SBAR | (situation, background, assessment, recommendation) a method of communication among health care workers and a part of documentation |
| SOAPE | the briefer adaptation of the charting format for the POMR |
| SOAPIER (SOAPE documentation) | an acronym for seven different aspects of charting |
| What does SOAPIER stand for? | subjective, objective, assessment, plan, intervention, evaluation, revision |
| traditional (block) chart | divided into sections or blocks; emphasis is placed on specific sections of information |
| assessment | a systematic, dynamic, way to collect and analyze data about a client, the first step in delivering nursing care |
| nursing process | a systematic method by which nurses plan and provide care for patients |
| outcomes | something that person strives to achieve |
| What is nursing? | protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy, in the care of individuals, families, groups, communities, and population |
| what does an assessment include? | not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well |
| what are two types of assessments? | Complete & Focus |
| complete assessment | involves a review and physical examination of all body systems |
| What is a focused assessment? | is advisable when the patient is critically ill, disoriented, or unable to respond |
| What type of data are we collecting? | Subjective and objective |
| cue | a piece or pieces that often indicate that an actual or potential problem has occurred or will occur |
| subjective data | information that is provided by patient |
| objective data | observable and measurable signs |
| biographic data | provide information about the facts or event's in a person life |
| diagnose | to identify the type and cause of a health condition |
| nursing diagnosis/patient problem statement | a type of health problem that can be identified by the nurse |
| What is NANDA-I | to reflect nursing diagnosis terminology uses around |
| database | a large store or bank of information |
| Data Clustering | the clustering of related data helps to identify patterns that assist with the identification of patient's health problems |
| patient problem statements | used to guide the development of a nursing care plan |
| Who's responsibility is the assessment and development of nursing diagnosis or patient problems | RN |
| If the nurse is not able to prescribe the primary treatment, then what? | the problem is not a nursing diagnosis or patient problem |
| when identifying patient problems, consider what factors? | patient's presenting signs and symptoms; contributing, etiologic (causative), and related factors; and defining characteristics |
| potential patient problems | are written as two part statements (1) patient problem statement with adjective "potential" in front of it (2)the risk factors |
| collaborative problems | health-related problems that the nurse anticipates based on the condition or diagnosis of a patient |
| medical diagnosis | the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review, laboratory tests, diagnostic procedures, review of medical records, and patient history |
| goal | the purpose to which an effort is directed |
| What should the goal statement start with? | the patient WILL |
| what are measurable verbs ? | indicates the precise behavior that the nurse anticipates hearing or seeing such as define, describe, list, walk, demonstrate, and verbalize |
| planning | phase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the patient problem statement |
| nursing interventions | activities that promote the achievement of the desired patient goal |
| physician-prescribed interventions | actions ordered by the physician for a nurse or health care professional to perform |
| nurse prescribed interventions | any actions that a nurse is legally able to order or begin independently |
| once patient problems have been identified the RN must prioritized the patient problem according to the the patent's current health status by using _____ | Maslow's Hierarchy of needs |
| implementation | phase of the nursing process, the nurse and other members of the team put the established into action to promote goal achievement |
| evaluation | a determination made about the extent to which he established goals have been achieved |
| includes the subject, action verb, and qualifying details; must be easy to interpret, very specific | written nursing interventions |
| standardized language | terms that have the same definition and meaning regardless of who uses them |
| nursing sensitive patient outcomes | results of outcomes of nursing interventions. these outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices |
| managed care | refers to health care systems that have control over primary health care services and attempt to trim down health care costs by reducing unnecessary or overlapping services; an emphasis is placed on health promotion, education, and preventive medicine |
| What are the 5 purposes for keeping patient records? | Accountability, Documented communication, legal record of care, teaching, & research/data collection |
| what is the nursing process? | Assessment, diagnosis, planning, outcome identification, implementation, evaluation |
| assessment | collecting & analyzing data of patient |
| diagnosis | identifying type & cause of health condition |
| outcome identification | individualized goals or expected outcomes associated with the nursing diagnosis |
| planning | priorities of care established interventions are chose |
| implementation | perform the action identified in planning |
| evaluation | determine if goals met and outcomes achieved |
| what is the patient chart considered? | a legal document |
| what does the extra R in SBARR stand for? | Read back |
| what is required for a nursing license? | need to know guidelines of documentation |
| If it wasn't documented | It didn't happen |
| How long do you have to stay in a facility in order for insurance to cover it? | short term stay, at least 3 nights |
| Using SBAR format, what do you do when receiving a doctor's order over the phone? | Always clarify with the doctor about the order given |
| EHR | info goes straight to pharmacy, also used to order diagnostic tests |
| What time should only be used in nursing notes? | military |
| In nursing notes you never include what? | incident reports |
| SOAP notes are considered? | problem oriented |
| The lower the acuity # means? | the higher the care |
| Method of Recording | Traditional Chart (Block Charting) |
| Narrative Charting | Descriptive Form |
| Focus Charting Format | D.A.R.E. |
| What does D.A.R.E stands for? | Data, Action, Response, Evaluation |
| Clincal Pathways | allows staff from all disciplines to develop standardized, integrated care plans for a longer length of stay for patients of a specific case type |
| OBRA(Ombinus Budget Reconciliation Act) | signifies medicare & medicaid requirements for long term care |
| property of the institution or the health care provider | original health care record |
| what does a patient has to do to gain access to their health records? | follow established policy |
| What must a student nurse or nurse NEVER do? | no information or documents stating patients' info should be left behind, alone or shared |
| What is evidence-based? | nursing research |
| The framework to organize individualized nursing care | nursing process |
| Thinking with a purpose is | critical thinking |
| Primary source | patient only source of data |
| Secondary source | the rest involved |
| What is data clustering? | defining characteristics |
| Nanda | definition of nursing diagnosis terminology |
| medical diagnosis | identification of the disease |
| variance | when a patient doesn't achieve patient outcome |
| What are SMART goals? | specific, measurable,attainable, realistic, timing |
