Chapter 17: Documenting, Reporting, COnferring and Using Informatics
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Lizabean64 on January 28, 2012
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25 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 | shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to those standards are documented in narrative notes |
| Critical/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 |
| 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 or experience and expertise deliberate about a problem and its solution |
| 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 Records (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 (ex. vitals, routine aspects or care) |
| Focus Charting | a documentation 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; 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 patient, employee or visitor |
| Minimum Data Set | a standard established by healthcare institutions that specifies the information that must be collected from every patient |
| Narrative Notes | progress notes written by nurses in a source oriented record |
| Outcome and Assessment Information Set (OASIS) | assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home care patients and forms the basis for measuring patient outcomes for the purpose of improving the quality of care that is provided |
| 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 Records (PHRs) | 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 (POR) | documentation system organized according to the person's specific health problem; includes database, problem list, plan of care and progress notes |
| Progress Notes | ant 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 | consistent, clear, structured and easy-to-use method of communication between healthcare personnel; it organizes communication by the categories of: Situation, Background, Assessment 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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