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Chapter 7 Key Terms

auditors people appointed to examine patient charts and health records to assess the quality of care
chart (health care record) legal record that is used to meet many demands of the health accreditation, medical insurance, and legal systems
charting process of recording information on a patient’s chart
charting by exception (CBE) recording only new data or changes in patient status or care; charting the exceptions to the previously recorded data
database large store or bank of information, as in forming the patient’s nursing diagnoses
diagnosis- related groups (DRGs) system that classifies patient by age, diagnoses, and surgical categories; used to predict the use of hospital resources, including the length of stay
documenting process of adding information to the chart, usually at prescribed intervals
Kardex (or Rand) a card system used to consolidate patient orders and care needs in a centralized, concise way
narrative charting traditional system of charting in which the nurse documents in story form all pertinent patient observations
nomenclature a classified system of technical or scientific names and terminology
nursing care plan plan of care based on a nursing assessment and nursing diagnosis; lists nursing actions necessary to meet a patient’s needs
nursing notes the form on the patient’s chart on which nurses record their observations, care given, and the patient’s responses
peer review an appraisal by professional co-workers (of equal status) or the way an individual nurse conducts practice, education, or research
problem list prioritized master list of the patient’s active, inactive, temporary, and at-risk medical or other problems; serves as an index to the rest of the record
problem- oriented medical record (POMR) method of recording data about the health status of a patient in a problem-solving system. Parts included are the databases, problem list, initial plan, and progress notes
quality assurance, assessment and improvement in health care, any evaluation of services provided and the results achieved as compared with accepted standards
recording process of adding written information to the chart, usually at prescribed intervals
SOAPE (S) reported by the patient; objective data (O) acquired by inspection, percussion, auscultation, and palpation and by tests; assessment (A) of the problem; plan (P) of care; and evaluation (E) of the patient’s response to the treatment
SOAPIER Same as SOAPE charting except that intervention (I) and revision (R) are added. Interventions are specific actions carried out, and revisions are the changes to be made to the original plan
traditional (block) chart conventional patient chart broken down into sections or blocks; included are admission data, physician’s orders, history and physical examination, nursing care plan, nurses’ notes and graphics, progress notes, and test data
Created by: stjean224