Chap.17 Documenting, Reporting, Conferring, and Using Informatics
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26 terms
Terms | Definitions |
|---|---|
 change-of-shift report | communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped |
| charting by exception (CBE) | shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes |
| collaborative pathway | case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions. same as critical pathway |
| confer | to consult with someone to exchange ideas or to seek information, advice, or instructions |
| consultation | process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution |
| critical pathway | case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions. same as collaborative pathway |
| discharge summary | description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received including referrals |
| documentation | written, legal record of all pertinent interventions with the patient-- assessments,diagnoses, plans, interventions, and evaluations |
| electronic medical record (EMR) | computer-based records or data that can be distributed among many caregivers in a standardized format |
| flow sheet | graphic record of abbreviated aspects of patient's condition (e.g., vital signs, routine aspects of care) |
| focus charting | adocumentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format |
| graphic sheet | form used to record specific patient variables |
| incident report | tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patuent, employee, or visitor |
| narrative notes | progress notes written by nurses in a source-oriented record |
| nursing informatics | specialty that intergrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice |
| OASIS | ... |
| patient record | a compilation of a patient's health information; the patient record is the only permanent legal document that details the nurse's interactions with the patient |
| personal health record (PHR) | information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications |
| PIE charting | documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number worked up using the problem (P), intervention (I), evaluation (E), format, and evaluated each shift |
| problem-oriented medical record (POMR) | documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes |
| progress notes | any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes |
| referral | process of sending or guiding someone to another source for assistance |
| SBAR communication | consistent, clear, structured, and easy-to-use method of communication between healthcare personnel; it organizes communication by the catefirues of: Situation, Background, Assesment, and Recommendations |
| SOAP format | method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and Plan (P) |
| source-oriented record | documentation system in which each healthcare group records data on its own separate form |
| variance charting | documentation method in case management that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate |
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