Ch 19 Documenting and reporting

Question 1

Bedside report

Answer 1

Standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family

Question 2

Change of shift report

Answer 2

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

Question 3

Charting by exception CBE

Answer 3

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

Question 4

Confer

Answer 4

To consult with someone to exchange ideas or to seek information, advice, or instructions

Question 5

Consultation

Answer 5

Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

Question 6

Critical/collaborative pathway

Answer 6

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

Question 7

Discharge summary

Answer 7

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

Question 8

Documentation

Answer 8

Written, legal record of all pertinent interventions with the patient assessments, diagnosis, plans, interventions, and a evaluations

Question 9

Electronic health record EHR

Answer 9

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

Question 10

Flow sheet

Answer 10

Graphic record of abbreviated aspects of the patient’s condition i.e. vital signs, routine aspects of care

Question 11

Focus charting

Answer 11

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

Question 12

Graphic record

Answer 12

Form used to record specific patient variables

Question 13

Handoff

Answer 13

A nurses report to another nurse or healthcare provider about a patient status and progress

Question 14

Health information exchange HIE

Answer 14

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

Question 15

Incident report

Answer 15

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

Question 16

ISBAR communication

Answer 16

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

Question 17

Minimum data set

Answer 17

A standard established by healthcare institutions that specifies the information that must be collected from every patient

Question 18

Narrative notes

Answer 18

Progress notes written by nurses in a source oriented record

Question 19

Occurrence charting

Answer 19

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

Question 20

Outcome and assessment information set OASIS

Answer 20

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

Question 21

Patient record

Answer 21

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

Question 22

PIE charting

Answer 22

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

Question 23

Problem oriented medical record POMR

Answer 23

Documentation system organized according to the person specific health problems; includes database, problems, plan of care, and progress notes

Question 24

Progress notes

Answer 24

Any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes

Question 25

Purposeful rounding

Answer 25

Proactive, systematic, nurse driven, evidence based intervention that helps nurses anticipate an address patient needs

Question 26

Read back

Answer 26

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

Question 27

Referral

Answer 27

Process of sending or guiding someone to another source for assistance

Question 28

SOAP format

Answer 28

Method of charting narrative progress notes; organizes data according to subjective information S, Objective information O, assessment A, and plan P

Question 29

Source oriented record

Answer 29

Documentation system in which each healthcare group records data on its own separate form

Question 30

Variance charting

Answer 30

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

Question 31

Variance report

Answer 31

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