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Docu & info
Def
| Question | Answer |
|---|---|
| accreditation | process whereby a professional association or nongovernmental agency grants recognition to a school/institution for demonstrated ability to meet predetermined criteria |
| acuity records | mechanism by which entries describing pt. care activities are made over a 24-hr period. The activities are then translated into a rating score, or acuity score, that allows for a comparison of pts. who vary by severity of illness |
| case management | organized system for delivering health care to an individual pt. or group of pts. across an episode of illness and/or continuum of care |
| charting by exception | charting methodology in which data are entered only when there is an exception from that which is normal or expected |
| clinical decision support system (CDSS) | computerized programs used w/in the health care setting to support decision-making |
| computerized provider order entry (CPOE) | comprehensive computerized system used by all health care practitioners to permanently store information pertaining to a pts. health status, clinical problems, and functional abilities |
| consultations | Process in which the help of a specialist is sought to identify ways to handle problems in pt. management or in planning and implementing programs |
| critical pathways | tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a pt---used to manage the care of a pt throughout a projected length of stay |
| DAR (data, action, patient response) | format used in focus charting for recording patient information |
| Group of pts. classified to establish a mechanism for health care reimbursement based on length of stay | Diagnosis-related group (DRG) |
| written entry into the pts medical record of all pertinent info about him/her. These entries validate the pts. problems and care and exist as a legal record. | documentation |
| an electronic record of pt health info generated whenever a pt accesses medical care in any health care delivery setting | electronic health record (EHR) |
| part of the electronic health record that contains pt data gathered in a health care setting at a specific time and place | electronic medical record (EMR) |
| A combination of hardware and software that protects private network resources | firewall |
| documents on which frequent observations or specific measurements are recorded | flow sheets |
| charting methodology for structuring progress notes according to the focus of the note. Each note includes data, actions, and pt response | focus charting |
| happen any time one health care provider transfers care of pt to another | Hand-off reports |
| applications in computers and information science in all basic and applied biomedical sciences to facilitate the acquisitions, processing, interpretations, optimal use, & communication of health-related data | health informatics |
| confidential document that describes any pt accident while the person is on the premises of a health care agency | incident (occurrence) report |
| refers to the management and processing of information, generally w/ the assistance of computers | information technology |
| Kardex | trade name for card filing system that allows quick reference to the particular need of the pt.for certain aspects of nursing care |
| Nursing informatics | is a specialty that integrates nursing science, computer science & information science to manage and communicate data, info, and knowledge |
| PIE (problem-intervention-evaluation) | problem oriented medical record; the 4 interdisciplinary sections are the database, problem list, care plan, & progress note |
| problem -oriented medical record (POMR) | method of recording data about the health status of a pt that fosters a collaborative problem-solving approach by all members of the health care team |
| referrals | an arrangement for services by another care provider |
| soap (subjective-objective-assessment-plan) | Subjective data (verbalization of the pt) Objective data (which is measured and observed) Assessment (diagnosis based on the data) Plan (what the caregiver plans to do) |
| soapie | Subjective data (verbalization of the pt) Objective data (which is measured and observed) Assessment (diagnosis based on the data) Plan (what the caregiver plans to do) Intervention and Evaluation |
| source record | organization of a pts chart so each discipline has a separate section in which to record data. Unlike POMR, the info is not organized by pt problem. Caregivers can easily locate proper sections to document. |
| Standardized care plans | written care plans used for groups of pts who have similar health care problems |
| Variances | Unexpected event that occurs during pt care and that is different from CareMap predictions. These are interventions or outcomes that are not achieved as anticipated. |
Created by:
ldepina20
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