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| accreditation | process whereby a professional association or nongovernmental agency grants recognition to a school/institution for demonstrated ability to meet predetermined criteria
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| acuity records | mechanism by which entries describing pt. care activities are made over a 24-hr period. The activities are then translated into a rating score, or acuity score, that allows for a comparison of pts. who vary by severity of illness
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| case management | organized system for delivering health care to an individual pt. or group of pts. across an episode of illness and/or continuum of care
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| charting by exception | charting methodology in which data are entered only when there is an exception from that which is normal or expected
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| clinical decision support system (CDSS) | computerized programs used w/in the health care setting to support decision-making
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| computerized provider order entry (CPOE) | comprehensive computerized system used by all health care practitioners to permanently store information pertaining to a pts. health status, clinical problems, and functional abilities
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| consultations | Process in which the help of a specialist is sought to identify ways to handle problems in pt. management or in planning and implementing programs
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| critical pathways | tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a pt---used to manage the care of a pt throughout a projected length of stay
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| DAR (data, action, patient response) | format used in focus charting for recording patient information
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| Group of pts. classified to establish a mechanism for health care reimbursement based on length of stay | Diagnosis-related group (DRG)
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| written entry into the pts medical record of all pertinent info about him/her. These entries validate the pts. problems and care and exist as a legal record. | documentation
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| an electronic record of pt health info generated whenever a pt accesses medical care in any health care delivery setting | electronic health record (EHR)
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| part of the electronic health record that contains pt data gathered in a health care setting at a specific time and place | electronic medical record (EMR)
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| A combination of hardware and software that protects private network resources | firewall
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| documents on which frequent observations or specific measurements are recorded | flow sheets
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| charting methodology for structuring progress notes according to the focus of the note. Each note includes data, actions, and pt response | focus charting
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| happen any time one health care provider transfers care of pt to another | Hand-off reports
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| applications in computers and information science in all basic and applied biomedical sciences to facilitate the acquisitions, processing, interpretations, optimal use, & communication of health-related data | health informatics
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| confidential document that describes any pt accident while the person is on the premises of a health care agency | incident (occurrence) report
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| refers to the management and processing of information, generally w/ the assistance of computers | information technology
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| Kardex | trade name for card filing system that allows quick reference to the particular need of the pt.for certain aspects of nursing care
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| Nursing informatics | is a specialty that integrates nursing science, computer science & information science to manage and communicate data, info, and knowledge
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| PIE (problem-intervention-evaluation) | problem oriented medical record; the 4 interdisciplinary sections are the database, problem list, care plan, & progress note
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| problem -oriented medical record (POMR) | method of recording data about the health status of a pt that fosters a collaborative problem-solving approach by all members of the health care team
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| referrals | an arrangement for services by another care provider
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| soap (subjective-objective-assessment-plan) | Subjective data (verbalization of the pt)
Objective data (which is measured and observed)
Assessment (diagnosis based on the data)
Plan (what the caregiver plans to do)
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| soapie | Subjective data (verbalization of the pt)
Objective data (which is measured and observed)
Assessment (diagnosis based on the data)
Plan (what the caregiver plans to do)
Intervention and Evaluation
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| source record | organization of a pts chart so each discipline has a separate section in which to record data. Unlike POMR, the info is not organized by pt problem. Caregivers can easily locate proper sections to document.
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| Standardized care plans | written care plans used for groups of pts who have similar health care problems
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| Variances | Unexpected event that occurs during pt care and that is different from CareMap predictions. These are interventions or outcomes that are not achieved as anticipated.
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