| what is Chart (health care record) | it is a legal record that is used to meet the many demands of the health, accreditation, medical insurance and legal system. |
| what are the 5 purposes of documentation | documented communication, permanent record for accountability, legal record of care, teaching, research and data collection |
| auditors | people appointed to examine patients charts and health records to assess quality of care |
| peer review | an appraisal by professional coworker of equal status |
| quality assurance, assessment, and improvement | an audit in health care that evaluates services provided and the results achieved compared with accepted standards |
| diagnosis- related groups ( DRGs) | prospective payment system classified by age, diagnosis, surgical procedures, length of stay, etc |
| what is the nursing process ADPIE | assessment, diagnosis, outcome identification/planning, implementation, evaluation |
| nursing notes | the form of the patients charts on which nurses record their observations, the care given, and the patients responses |
| SBAR()R stand for | Situation, Background, Assessment, Recommendation, (Read back) |
| what does EHR increase | efficiency, consistency, and accuracy and decrease cost |
| what isa benefit of EHR | ability for all health care providers to view a patients records, encouraging increased continuity of care |
| point of care POC | computer input only at the nurses station, some facilities have bedside systems and hand held systems |
| COW computers on wheels | poc charting system are housed on wheeled carts |
| nomenclature | a classified system of technical or scientific names or terminology |
| informatics | the study of information processing |
| personal health record (PHR) | is an extension or the EHR that allows patient to input their information into an electronic database |
| what is SBAR considered | a safety measure in preventing errors from poor communication during interaction between health care personnel, the communication from one shift to the next, or when a nurse phones a health care provider with information about a patient |
| when do you use the R in SBARR | When you take a phone order or when talking to the Dr. always Read back what they said to ensure what the nurse heard was correct |
| What does the LVN need to ensure when charting | information is clear, concise, complete and accurate |
| Traditional (block) chart | is decided into sections or blocks. emphasis is placed on specific sections( or sheets for non computerized charts) of information. |
| narrative charting | where the nurse records patient care in a descriptive form, in chronological order |
| problem-oriented medical record (POMR) | is organized according to the scientific problem-solving system or method |
| database | a large store or bank of information, such as informing the patient nurse diagnosis |
| problem list | active, inactive, potential, and resolved problems served as the index for chart documentation |
| SOAPIER | acronym for 7 different aspects of charting for notes on specific problems |
| S-subjective | information is what the patient states or feels; only the patient can tell this information |
| O-objective | information is what the nurse can measure or factually describe |
| A-assessment | refers to analysis or potential diagnosis of the cause of the patients problems or needs |
| P-plan | is the general statement of the plan of care being given or action to be taken |
| I-intervention or implementation | is the specific care given or action taken |
| E-evaluation | is an appraisal of the response and effectiveness of the plan |
| R-revision | includes the changes that may be made to original plan of care |
| kardex(rand) | consolidate patient orders and care needs in a centralized, concise way |
| nursing care plan | outlines the proposed nursing care based on the nursing assessment and the identified problems to provide continuity of care |
| incident report | form used to document any event not consistent with routine operation of health care unit or the routine care of a patient |
| what do you include in incident report | objective, observed information |
| what do you not include in an incident report | do not admit liability and unnecessary information |
| when charting why do you not mention an incident report | doding so makes it easier for an attorney to request that documentation for a court case |
| 24 hr patient care records | provide foundation for acuity chart system |
| acuity charting | uses a score that rates each patient by severity of illness ( level 1 requires almost all of your time like a patient out of surgery level 5 minimal time like just passing meds) |
| what is one benefit of acuity charting | the ability to determine efficient staffing patterns according to the acuity levels of the patient on a particular nursing unit |
| discharge summary | form that provides information that pertains to the patients continued health care after discharge |
| clinical (critical) pathways | allow staff from all discipline(dr, pt, to,nurses etc) to develop standardized, integrated care plans for a projected length of stay for a specific case type (diagnosis) |
| home health care documentation | document in detail any procedures, treatments, medications administered and response to these interventions , education and demonstrating of leaning |
| what does OBRA ( ominous budget reconciliation act) require | regulated standards for resident assessments, individualized care plans, and qualifications for health care providers |
| who owns the healthcare record or chart of the patient | the institution or healthcare provider |
| how can a lawyer get the patients records | with the patients written consent |
| what does student nurses need to know | no information is to leave the clinical site, any documents with patient identifiers must be safely guarded at all times in the facility, must shred all papers or notes with patient information on it prior to leaving the facility |
| what needs to be done prior to faxing information | verify the number before sending any patient information |
| nursing process | is a systematic method by which nurses plan and provide care for patients |
| assessment | a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care |
| definition of nursing | protection, promotion, optimization of health and abilities, prevention of illness & injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment to the human response, advocate in the care of individuals, families, groups, communities, and population |
| outcomes | outcome and goals are something that a person strives to achieve |
| cue | is a piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur |
| subjective data | information that the patient provides ( hide information until patient shares information) |
| objective data | are observable and measurable signs |
| biographic data | provides information about the facts or events in a persons life |
| database | a large stor or bank of information |
| diagnosis | is to identify the type and cause of a health condition |
| focused assessment | when patient is critically ill, disoriented, or unable to respond. a focused assessment is used to gather information about a specific health assessment |
| nursing diagnosis/ patient problem statement | is a type of health problem that can be identified by the nurse |
| NANDA-I | to reflect nursing diagnosis terminology used around the world |
| NANDA (I) acronym means what | North American Nursing Diagnosis Association International |
| actual patient problem statement | an actual patient problem statement identifies health-related problems that exist and are discovered during the nursing assessment |
| potential patient problems | are written as two part statements 1: the patient problem statement with adjective "potential" in front of it and 2: then risk(s) factors |
| defining characteristics | are the clinical cues, signs, and symptoms that furnish the evidence that the problem exists |
| Collaborative problems | are health- related problems that the nurse anticipates based on the condition or diagnosis of a patient |
| medical diagnosis | is the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, lab test, diagnostic procedures, review of medical records and patient history |
| goal | goal statement indicates the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement |
| 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 | are those activities that promote the achievement of the desired patient goal |
| implementation | the nurse and other members of the team put the established plan into action to promote goal achievement |
| evaluation | is determination made without the extent to which the established goals have been achieved |
| physician-prescribed interventions | are those actions ordered by a physician for a nurse or other health care professional to perform |
| nurse-prescribed interventions | ae the actions that a nurse is legally able to order or begin independently |
| what are nursing interventions often aimed at | reducing or eliminating the cause factor |
| properly written nursing interventions include what | specific for the problem, realistic for the patient, compatible with the medical plan of care, and based on specific evidence-based principles |
| implementation | the nurse and other members of the team put established plan into action to promote goal achievement |
| evaluation | is a determination made about the extent to which the established goals have been achieved |
| standardized language | terms that have the same definition and meaning regardless of who uses them |
| nursing sensitive outcomes | standardized system with an organized structure to name and measure |
| NIC | Nursing Interventions Classification |
| NOC | Nursing Outcome Classification |
| Managed care | refers to the health care system that have control over primary health care services and attempt to trim down healthcare costs by reducing unnecessary or overlapping services |
| case management | encompasses planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for the patient |
| clinical pathways | is a multidisciplinary plan that incorporates evidence-based practice guidelines for high-risk, high cost types, of cases while providing for optimal patient outcomes maximized clinical efficiency |
| variance | if a patient does not achieve the projected outcome |
| define critical thinkers | question information, conclusions, and points of view and look beneath the surface |
| the NLN defines critical thinking for nurses as what | a discipline-specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns |
| why is critical thinking essential | to provide quality nursing care for patients of various situations |
| how does the ANA define evidence-based practice | a scholarly systematic problem-solving paradigm that results in the delivery of high-quality health care |
| definition of the nursing process | is a brainwork by which to organize individualized nursing care |
| how many types of data are there | two, primary and secondary |
| what is primary data | from the patient if alert and oriented |
| what is secondary data | include family members, significant others, medical records, diagnostic procedures, and previous nursing notes |
| who can provide a medical diagnosis | physician or other medical qualified health care provider such as nurse practitioner |
| what is the first method of data collection | the nurse conducts an interview, the nursing health history, to obtain information about the patients health history |
| what is the second method of data collection | physical examination |
| what is data clustering | data obtained from health history, physical examination, and related diagnostic procedures are analyzed in development of a care plan |
| according to NANDA-I what does the nursing diagnosis do | provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability |
| what is the RN permitted legally to do | identify and prescribe the primary interventions to treat or prevent problems that are identified as a nursing diagnosis or patient problem |
| as a member of the healthcare team what does the LVN actively participate in | patient care planning and collaborating with the RN to update thecae plan and implement prescribed nursing interventions |
| what are patient problem statements used to for | to guide the development of a nursing care plan |
| chronic conditions | are always present or consistently recur commonly or last 3 months or longer |
| what does the nursing assessment determine | how to classify the problem |
| if the patients condition is expected to change what do you add | "Potential for" before the patient problem statement |
