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nursing 203

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
Created by: 691650210