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Fundamentals Ch. 10

Informatics and Documentation Key Terms

accreditation Process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet predetermined criteria.
acuity recording Mechanism by which entries describing patient care activities are made over a 24-hour period. The activities are then translated into a rating score, or acuity score, that allows for a comparison of patients who vary by severity of illness.
case management plan A multidisciplinary model for documenting patient care that usually includes plans for problems, key interventions, and expected outcomes for patients with a specific disease or condition.
change-of-shift report Report that occurs between two scheduled nursing work shifts. Nurses communicate information about their assigned patients to nurses working on the next shift of duty.
charting by exception (CBE) Charting methodology in which data are entered only when there is an exception from what is normal or expected. Reduces time spent documenting in charting. It is a shorthand method for documenting normal findings and routine care.
clinical decision support system (CDSS) Computerized programs used within a health care setting to guide interventions.
computerized provider order entry (CPOE) One type of order entry system gaining popularity across the country, particularly with medication orders.
confidentiality The act of keeping info. private or secret; in health care, the nurse only shares info. about a patient with other nurses or health care providers who need to know info. about a patient in order to provide care for the patient; patient consent needed.
diagnosis-related group (DRG) Group of patients classified to establish a mechanism for health care reimbursement based on length of stay; classification is based on the following variables: primary and secondary diagnosis, comorbidities, primary & secondary procedures and age.
documentation Written entry into the patient's medical record of all pertinent information about the patient. These entries validate the patient's problems and care and exist as a legal record.
electronic health record (EHR) A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.
firewall A combination of hardware and software that protects private network resources from outside hackers, network damage, and theft or misuse of information.
flow sheets Documents on which frequent observations or specific measurements are recorded.
focus charting A charting methodology for structuring progress notes according to the focus of the note, for example, symptoms and nursing diagnosis. Each note includes data, actions, and patient response.
graphic records Charting mechanism that allows for the recording of vital signs and weight in such a manner that caregivers can quickly note changes in the patient's status.
hand-off report Occurs any time one health care provider transfers care of a patient to another health care provider.
health care information system (HIS) A group of systems used within a health care enterprise that support and enhance health care.
incident (occurrence or event) report Confidential document that describes any patient accident while the person is on the premises of a health care agency.
informatics The science and art of turning data into information.
information technology The management and processing of information, generally with the assistance of computers.
interdisciplinary care plan Disciplines involved in the patient's care develop a care plan for each problem listed.
Kardex Trade name for the card-filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care.
meaningful use Level which info. tech. (IT) is available and used to support clinical decision making to improve quality, safety, efficiency; reduce health disparities; engage patients & families in their health care; improve care coordination population public health
nursing informatics A nursing specialty that manages and communicates data, information, knowledge, and wisdom by integrating nursing, computer and information science.
password A collection of alphanumeric characters that a user types into the computer before assessing a program.
PIE note Problem-oriented medical record; the four interdisciplinary sections are the database, problem list, care plan, and progress notes.
problem-oriented medical record (POMR) Method of recording data about the health status of a patient that fosters a collaborative problem-solving approach by all members of the health care team.
record Written form of communication that permanently documents information relevant to health care management.
report Transfer of information from the nurse on one shift to the nurse on the following shift. Report may also be given by one of the members of the nursing team to another health care provider, for example, a physician or therapist.
SOAP note Progress note that focuses on a single patient problem and includes subjective and objective data, analysis, and planning; most often used in the POMR.
standardized care plan Written care plans that are based on an institution's standards of practice and established guidelines and are used to care for patients with similar health problems. These care plans assist in accurate and efficient documentation.
transfer report Verbal exchange of information between caregivers when a patient is moved from one nursing unit or health care setting to another. The report includes information necessary to maintain a consistent level of care from one setting to another.