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Docu & info

Def

QuestionAnswer
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