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VNPT51 CH.3 Terms

VNPT51 CHAPTER 3 DOCUMENTATION-mb

TermDefinition
Auditors People appointed to examine patient charts and health records to assess the quality of care
chart A legal record that is used to meet the many demands of the the health, accreditation, medical insurance, and legal systems
charting, recording Process of recording information on a patient
charting by exception (CBE) recording only new data or changes in patient status or care; charting the exceptions to the previously
computer on wheels Electronic systems that are housed on carts
database Large store or bank of information, as in forming the patient's nursing diagnosis
diagnosis-related groups System that classifies patients by age, ailment, 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
electronic health record (EHR) An electronic patient record designed for health information exchange between facilities
electronic medical record (EMR) An electronic patient record designed for health information exchange only within a single facility
informatics The study of information processing
Kardex (or Rand) A 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 all pertinent patient observations, care, and responses in story form in the nurse's notes section of the patient's record
nonmenclature A classified system of technical or scientific names and terminology
nursing care plan Plan of care based on nursing assessment and a 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 coworkers of equal status on the way an individual nurse conducts practice, education, or research
personal health record An electronic record in which patients are allowed to input and update their own health information
point-of-care Computer electronic health record systems that are located at the patient's bedside
problem list Prioritized master list of the patient's active, inactive, temporary, and at-risk medical issues; 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 database, 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; involves assessment and improvement
SBAR A method of communication among health care workers and a part of documentation; considered a safety measure in preventing errors from poor communication during hand-off or hand-over interactions
SOAPE Brief acronym used for the charting format for the POMR Subjective Objective Assessment Plan Evaluation
SOAPIER Complete acronym used for the charting format for the POMR Subjective Objective Assessment Plan Intervention Evaluation Revision
traditional (block) chart Conventional patient chart broken down into sections or blocks; included are admission data, health care provider's orders, history and physical examination, nursing care plan, nurse's notes and graphics, progress notes, and test data
Created by: barragan_93230