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Recording&Reporting

Words to know from Ch 9 of Fundamentals

TermDefinition
Auditors inspectors who examine client records.
Beneficial disclosures an exemption whereby an agency can release private health info without a client's prior authorization.
Change-of-shift report is a discussion between a nursing spokesperson from the shift that is ending and the arriving personnel.
Chart a binder or folder that promotes the orderly collection, storage and safekeeping of a person's medical record.
Charting the process of entering information.
Charting by exception documentation method in which only abnormal assessment findings or care that deviates from the standard is charted.
Checklist a form of documentation in which the nurse indicates the performance of routine care with a check mark or initials.
Continuous quality improvement process of promoting care that reflects established agency standards.
Documenting the process of entering information.
Double charting repetitious entry of the same info in the medical record.
Electronic charting documenting client info with a computer.
Flow sheet a form of documentation with sections for recording frequently repeated assessment data.
Focus charting modified form of SOAP charting.
Health Insurance Portability and Accountability Act (HIPPA ) legislation that sets national standards for the security of health info, ensures that an individual's electronic, paper, or oral health info is protected.
Informatics collection, storage, retrieval, and sharing of recorded data.
Kardex a quick reference for current info about the client and his or her care.
Medical record a collection of info about a person's health.
Military time time based on a 24 hour clock.
Minimum disclosure information necessary for the immediate purpose only.
Narrative charting the style of documentation generally used in source-oriented records.
Nursing care plan a written or printed list of the client's problems, goals, and nursing orders for client care.
PIE charting a method of recording the client's progress under the headings of problem, intervention, and evaluation.
Problem-oriented record records organized according to the client's health problems.
Quality assurance process of promoting care that reflects established agency standards.
Recording the process of entering information.
Rounds visits to the bedside of clients on an individual basis or as a group.
SBAR format model for effective communication identifying Situation, Background, Assessment, and Recommendation.
SOAP charting the documentation style more likely to be used in a problem-oriented record. (S- subjective data, O- objective data, A- analysis of the data, P- plan for care)
Source-oriented record records organized according to the source of documented info.
Total quality improvement process of promoting care that reflects established agency standards.
Traditional time time based on two 12 hour revolutions on a clock.
Created by: Jessica Venyke