Upgrade to remove ads
INFORMATICS & DOCUMENTATION Key Terms
Ch 10 Essentials for Nursing - also see ch 14 Contemporary Nursing, & ch 4 in Potter Skills Book
Terms in this set (32)
Process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet predetermined criteria.
Mechanism by which entries describing patient care activities are made over a 24-hour period. The activities are then translated into a rating score, or acuity score, that allows for a comparison of patients who vary by severity of illness.
case management plan
A multidisciplinary model for documenting patient care that usually includes plans for problems, key interventions, and expected outcomes for patients with a specific disease or condition.
Report that occurs between two scheduled nursing work shifts. Nurses communicate information about their assigned patients to nurses working on the next shift of duty.
charting by exception (CBE)
Charting methodology in which data are entered only when there is an exception from what is normal or expected. Reduces time spent documenting in charting. It is a shorthand method for documenting normal findings and routine care.
clinical decision support system (CDSS)
Computerized programs used within a health care setting to guide interventions.
computerized provider order entry (CPOE)
one type of order entry system gaining popularity across the country, particularly with medication orders. Advantages of CPOE include reduced use of resources, quicker turnaround of orders, reduced length of stay, and an overall reduction in costs. More important, most CPOE systems have significant potential to reduce medication errors associated with illegibility and inappropriate drug use and dosing. CPOE refers to a process by which the health care provider directly enters orders for patient care into the hospital information system.
The act of keeping information private or secret; in health care, the nurse only shares information about a patient with other nurses or health care providers who need to know private information about a patient in order to provide care for the patient; information can only be shared with the patient's consent.
diagnosis-related group (DRG)
Group of patients classified to establish a mechanism for health care reimbursement based on length of stay; classification is based on the following variables: primary and secondary diagnosis, comorbidities, primary and secondary procedures, and age.
Written entry into the patient's medical record of all pertinent information about the patient. These entries validate the patient's problems and care and exist as a legal record.
electronic health record (EHR)
a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. It ensures coordination of care because all primary caregivers can view a common record of a patient's entire health care experience, including inpatient, outpatient, emergency care, and diagnostic studies. It integrates all pertinent patient information into one record.
a combination of hardware and software that protects private network resources (e.g., a hospital information system) from outside hackers, network damage, and theft or misuse of information.
Documents on which frequent observations or specific measurements are recorded.
A charting methodology for structuring progress notes according to the focus of the note, for example, symptoms and nursing diagnosis. Each note includes data, actions, and patient response.
Charting mechanism that allows for the recording of vital signs and weight in such a manner that caregivers can quickly note changes in the patient's status.
occurs any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients. A hand-off is the process
of transferring responsibility for patient care from one provider to another.
health care information system (HIS)
a group of systems used within a health care enterprise that support and enhance health care.
incident (occurrence or event) report
Confidential document that describes any patient accident while the person is on the premises of a health care agency.
the science and art of turning data into information. It focuses on information and knowledge acquisition rather than the computer.
information technology (IT)
efers to the management and processing of information, generally with the assistance of computers.
interdisciplinary care plan
Disciplines involved in the patient's care develop a care plan, for each problem listed. For example, a physical therapist communicates a plan for increasing a patient's ambulation, whereas a speech therapist communicates a plan to improve the patient's swallowing. Nurses document a plan of care in a variety of formats. Generally these plans of care include nursing diagnoses, expected outcomes, and interventions.
Trade name for card-filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care.
refers to the level with which information technology (IT) is available and used to support clinical decision making to improve quality, safety, and efficiency; reduce health disparities; engage patients and families in their health care; improve care coordination; improve population and public health; and maintain privacy and security.
a nursing specialty that manages and communicates data, information, knowledge, and wisdom by integrating nursing, computer, and information science. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings.
a collection of alphanumeric characters that a user types into the computer before accessing a program.
Problem-oriented medical record; the four interdisciplinary sections are the database, problem list, care plan, and progress notes.
problem-oriented medical record (POMR)
Method of recording data about the health status of a patient that fosters a collaborative problem-solving approach by all members of the health care team.
Written form of communication that permanently documents information relevant to health care management.
Transfer of information from the nurses on one shift to the nurses on the following shift. Report may also be given by one of the members of the nursing team to another health care provider, for example, a physician or therapist.
Progress note that focuses on a single patient problem and includes subjective and objective data, analysis, and planning; most often used in the POMR.
standardized care plans
Written care plans that are based on an institution's standards of practice and established guidelines and are used to care for patients with similar health problems. These care plans assist in accurate and efficient documentation.
Verbal exchange of information between caregivers when a patient is moved from one nursing unit or health care setting to another. The report includes information necessary to maintain a consistent level of care from one setting to another.
Sets with similar terms
Fundamentals Potter & Perry Chapter 26
NP Ch. 10
Potter/Perry Chapter 26 Informatics
Other sets by this creator
Comp predictor study guide
TEST 4 OXYGENATION
NCLEX-RN U-WORLD REVIEW