Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NURS 202 Exam 4
Chapters 10, 11, and 27
| Term | Definition |
|---|---|
| Health Care Documentation | may be written (paper) or electronic (EMR) |
| Medical Record | document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data |
| Electronic Medical Record (EMR) | a record of one episode of care, such as an inpatient stay or an outpatient appointment |
| Electronic Health Record (EHR) | a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings |
| Computerized Provider Order Entry (CPOE) | allows clinicians to enter orders in a computer that are sent directly to the appropriate department |
| WOW | work stations on wheels |
| Nursing Process | - Assessment - Diagnosis - Planning - Implementation - Evaluation |
| Expected Nursing Documentation | - nursing assessment - care plan - interventions - patient's outcomes or response to care - assessment of patient's ability to manage after discharge |
| PIE | problem, intervention, evaluation |
| APIE | assessment, problem, intervention, evaluation |
| SOAP | subjective data, objective data, assessment, plan |
| SOAPIE | subjective data, objective data, assessment, plan, intervention, evaluation |
| SOAPIER | subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan |
| DAR | data, action, response |
| CBE | charting by exception |
| Problem-Oriented Medical Record (POMR) | integrates charting from the entire care team in the same section of the record |
| Narrative Charting | is chronological, with a baseline recorded on a shift-by-shift basis |
| Formatted Charting | problem-oriented documentation can be completed in a variety of formations and follows a selected structure |
| Charting by Exception (CBE) | documentation that records only abnormal or significant data |
| Case Management Documentation | monitors patient outcomes on a regular basis |
| Flow Sheets | used to document routine care; vital signs, medications, and I/O measurements |
| Medication Administration Record (MAR) | list of ordered medications, along with dosages, routes, and times of administration |
| Bar-Coded Medication Administration (BCMA) | using a portable scanner, nurse scans the patient's wristband and the medication given |
| Kardex | nonpermanent filing system for nursing records, orders, and patient information that was held centrally on the unit |
| Admission Summary | includes patient's history, medication reconciliation, and an initial assessment that addresses patient's problems |
| Discharge Summary | addresses patient's hospital course and plans for follow-up, and it documents the patient's status at discharge, includes information on meds and treatment, discharge placement, patient education, follow-up appointments, and referrals |
| Confidentiality | patient information must be safeguarded and the information is shared only with individuals who have a need and a right to know |
| Privacy | right to be free from intrusion or disturbance in a person's private life |
| Health Insurance Portability and Accountability Act (HIPAA) | created standards for the protection of personal health information, whether conveyed orally or recorded in any form or medium |
| Hand-off | process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety |
| Sentinel Event | a safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life |
| SBAR | situation, background, assessment, reocmmendation |
Created by:
srpenapacheco
Popular Nursing sets