Taylor Fundamentals of Nursing chapter 17
documenting, reporting, conferring, and using informatics
Terms in this set (27)
change of shift report
communication method used by nursed who are completing are 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 these standards are documented in narrative notes.
interdependent nursing actions performed jointly by nurses and other members of the healthcare team.
to consult with someone to exchange ideas or to seek information, advice or instructions.
process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution.
thought that is disciplined, comprehensive, based on intellectual standards and as a result, well reasoned. a systematic way to form and shape one's thinking and functions purposefully and exactingly.
description of where the patient stand in relation to problems identified in the record at discharge, document any special teaching or counseling the patient received including referrals.
written, legal record or all pertinent interventions with the patient - assessments, diagnoses, plans, interventions and evaluations.
electronic medical record (EMR)
computer based records or data that van be distributed among many caregivers in a standardized format.
graphic record of abbreviated aspects of patient's condition.
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. the narrative portion of focus charging used the data, action and response format.
form used to record specific patient variables.
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.
progress notes written by nurses in a source oriented record.
specialty that integrates nursing science, computer science and the information science to manage and communicate data, information and knowledge in nursing practice.
outcome and assessment information set. assessment instrument representing core items of a comprehensive assessment for adult non-maternity home care patients and forms the basis of measuring patient outcomes for the purpose of improving the quality of care that is provided.
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 individuals medical history, including diagnoses, symptoms and medications.
documentation system that does not develop a separate care plan, the care plan is incorporated into the progress notes in which problems are identifies by number, worked up using the problem, intervention, evaluation 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 note.
any of a variety of methods of notes that related how a patient is progressing toward expected outcomes.
process of sending or guiding someone to another source for assistance.
consistent, clear, structures and easy to use method of communication between healthcare personnel, it organized communication by the categories: situation, background, assessment, and recommendation.
method of charging narrative progress notes, organized data according to subjective information: subjective data, objective data, assessment, and plan.
source oriented record
documentation system in which each healthcare group records data on its own separate form.
documentation method in care management that records unexpected events, the cause of an event, actions taken in response to the event and discharge planning when appropriate.
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