Ch 19 Documenting and reporting Flashcards
Bedside report
Standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family
Change of shift report
Communication method used by nurses who are completing care for 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 are based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
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/collaborative pathway
Case management plan that is a detailed, standardize 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
Discharge summary
Description of where the patient stands in relation to problems identified in the record of discharge; documents any special teaching or counseling the patient received including referrals
Documentation
Written, legal record of all pertinent interventions with the patient assessments, diagnosis, plans, interventions, and a evaluations
Electronic health record EHR
Digital version of a patient’s chart that may contain the patient’s medical history, diagnosis, medication, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
Flow sheet
Graphic record of abbreviated aspects of the patient’s condition i.e. vital signs, routine aspects of 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; the narrative portion of the focus chart uses data D, action A, responser, format
Graphic record
Form used to record specific patient variables
Handoff
A nurses report to another nurse or healthcare provider about a patient status and progress
Health information exchange HIE
An electronic system that allows physicians, nurses, pharmacist, other healthcare providers, and patients to appropriately access and securely share of patient’s vital medical information
Incident report
A report of any event that is not consistent with the routine operation of the healthcare facility that results in or has the potential to result in harm to a patient, employee, or visitor
ISBAR communication
A process for affective handoff communication among healthcare professionals about a patient’s condition standing for identity/introduction, situation, background, assessment, recommendation, and read back
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
Occurrence charting
Documentation when a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate; typically used for variances that affect quality, cost, or length of stay
Outcome and assessment information set OASIS
Assessment instrument representing core items of a comprehensive assessment for adult non-maternity home healthcare patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided
Patient record
A compilation of a patient’s health information; the patient record is the only permanent legal document that details the nurses interactions with the patient
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 evaluate at each shift
Problem oriented medical record POMR
Documentation system organized according to the person specific health problems; includes database, problems, 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
Purposeful rounding
Proactive, systematic, nurse driven, evidence based intervention that helps nurses anticipate an address patient needs
Read back
A process in which a nurse or other healthcare provider repeat a verbal order back to a physician to ensure that it was correctly heard and interpreted
Referral
Process of sending or guiding someone to another source for assistance
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 when a patient fails to meet an expected outcome or when a plan intervention is not implemented that records unexpected events, the cost for the event, actions taken in response to the event, and discharge planning when appropriate; typically used for variances that affect quality, cost, or length of stay; also called occurrence charting
Variance report
Tool used by healthcare facilities 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; also called an incident report or occurrence report
