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Con Ch. 6
Documentation
| Question | Answer |
|---|---|
| chart (health care record) | legal record used to meet the demands of the health, accreditation, medical insurance, and legal systems |
| charting, recording, or documenting | the process of adding written information to the chart |
| auditors | people appointed to examine patients' charts and health records to assess quality of care |
| peer review | an appraisal by professional co-workers of equal status |
| quality assurance/assessment/improvements | an audit in health care that evaluates services provided and the results achieved compared with accepted standards |
| diagnosis related groups (DRGs) | a system that classifies patients by age, diagnosis, and surgical procedure |
| nursing notes | the form on the patient's chart on which nurses record their observations, care given, and the patient's responses |
| traditional (block) chart | a chart divided into specific sections or blocks; emphasis placed on specific sheets of information |
| narrative charting | recording of patient care in descriptive form |
| problem-oriented medical record (POMR) | based on the scientific problem solving system or method; principle sections are database, problem list, care plan, and progress notes |
| database | the accumulated data from the history, physical exam, and diagnostic tests used to identify and prioritize the health problems on the master medical and other problems list |
| problem list | prioritized master list of the patient's active, inactive, temporary, and at-risk medical or other problems; serves as an index to the chart documentation |
| SOAPIER (SOAPE documentation) | an acronym for seven different aspects of POMR charting includes: SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN, INTERVENTION/IMPLEMENTATION, EVALUATION, REVISION |
| SOAPE | charting format used in POMR Components include SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN, and EVALUATION; briefer format for POMR |
| charting by exception (CBE) | recording only new data or changes in patient status or care; charting the exceptions to the previously recorded data |
| Kardex/Rand | card system used to consolidate patient orders and care needs in a centralized, concise way; kept at the nursing station for quick reference |
| nursing care plan | preprinted guidelines used to care for patients with similar health problems |
| Subjective (S) | information is what the patient states or feels; only the patient can provide this info |
| Objective (O) | info is what the nurse can measure or factually describe |
| Assessment (A) | refers to an analysis or potential diagnosis of the cause of a patient's problem or need |
| Plan (P) | general statement of the plan of care to be given or action to be taken |
| Intervention/Implementation (I) | specific care given or action taken |
| Evaluation (E) | an appraisal of the response and effectiveness of the plan |
| Revision (R) | includes the changes that may be made to the original plan of care |
| incident report | any event not consistent with the routine operation of a health care unit or the routine care of a patient |
| clinical (critical) pathways | allows staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type |
| computer-based records | electronic medical records that facilitate delivery of patient care and support the data analysis necessary for strategic planning; eliminate repetitive entries and allow more freedom of access to the database |
| Focus charting format | Data |
| Focus charting format | Data Action Response / evalutation Education / patient teaching |
Created by:
Jaybob
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