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VNPT51 CH.3 Terms
VNPT51 CHAPTER 3 DOCUMENTATION-mb
| Term | Definition |
|---|---|
| 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 |
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barragan_93230
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