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14-15
nursing 203
| Question | Answer |
|---|---|
| Implementation | refers to the action phase of the nursing process in which nursing car is provided. The actual initiation of the plan |
| Evaluation | as the judgement of the effectiveness of nursing care to meet patient goals based on the pt's behavioral response's |
| Standards of care | are authoritative statements made by nursing organizations that describe the responsibilities of the nursing profession |
| Quality improvement programs | are mechanisms for healthcare organizations to assess and improve care |
| peer review | is the evaluation and judgement of a nurse's performance by other nurses |
| nursing monitor | sometimes referred to as a nursing audit, is any review completed by a nurse of a patients care or records to evaluate whether established standards were met |
| documentation | written or typed communication |
| reporting | takes place when tow or more people share info about a pt, either face to face, audio-tape, or by telephone |
| audit | review of records |
| Never events | events that should never occur in a hospital setting |
| eMAR | interfaces medication orders w/ pharmacy dispensing and allows direct computer charting of medication |
| computerized physician oder entry (CPOE) | allows authorized providers to enter all orders directly into the computer |
| HIPPA | regulates all areas of info related to patients and being confidential |
| confidentiality | means keeping information private |
| point of care documentation | takes place as care occurs |
| batch charting | waiting until the end of the shift to chart information on patients |
| flow sheets | tables that have vertical and horizontal columns that allow nurses to document routine assessments and procedures |
| charting by exception | permits the nurse to document only those findings that fall outside the standard of care |
| SOAP note | a progress note that relates to only one health problem |
| plan of care | should be generated at admission and revised to reflect changes in the pt's condition |
| PIE charting | simplifies documentation by incorporating the plan of care in the progress notes |
| clinical pathways | way to guide the care of patients who have specific and generally predictable conditions |
| variance | a patient does not proceed along the pathway as planned |
| handoff | transfer of care for a patient from one health care provider to another |
| OASIS | the initial and ongoing assessment of all patients they care for to qualify for Medicare or Medicaid reimbursment |
| Resident Assessment Instrument (RAI) | governs documentation in long-term care settings |
| incident | any unusual happenings, such as a fall, med error ect |
| consult | need an expert opinion or specialized care for a patient |
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691650210
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