Chapter 10: Informatics and Documentation; Key Terms

Question 1

Accreditation

Answer 1

Process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet a predetermined criteria

Question 2

Acuity Recording

Answer 2

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

Question 3

Case Management Plan

Answer 3

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

Question 4

Change of Shift Report

Answer 4

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

Question 5

Charting by Exception (CBE)

Answer 5

Charting methodology in which data are entered only when there is an exception from what is normal or expected. Reduces times spent documenting in charting. It is a shorthand method for documenting normal findings and routine care

Question 6

Clinical Decision Support System (CDSS)

Answer 6

Computerized programs used within a health care setting to guide interventions

Question 7

Computerized Provider Order Entry (CPOE)

Answer 7

One type of order entry system gaining popularity across the country, particularly with medication orders.
A process by which the health care directly enters orders for patient care into the hospital information system

Question 8

Confidentiality

Answer 8

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

Question 9

Diagnosis-Related Group (DRG)

Answer 9

Group of patients classified to establish a mechanism for health care reimbursement based on the following variables; primary and secondary diagnosis, comorbidities, primary and secondary procedures, and age

Question 10

Documentation

Answer 10

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

Question 11

Electronic Health Record (EHR)

Answer 11

A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting

Question 12

Firewall

Answer 12

Combination of hardware and software that protects private network resources

Question 13

Flow Sheets

Answer 13

Documents on which frequent observations or specific measurements are recorded

Question 14

Focus Charting

Answer 14

A charting methodology for structuring progress notes according to the focus of the note, for example, symptoms and nursing diagnosis. Each notes includes data, actions, and patient response

Question 15

Graphic Record

Answer 15

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

Question 16

Hands-Off Report

Answer 16

Anytime one health care provider transfers care of a patient to another health care provider

Question 17

Health Care Information System (HIS)

Answer 17

A group of systems used within a health care enterprise that support and enhance health care

Question 18

Incident (Occurrence of Event) Report

Answer 18

Confidential document that describes any patient accident while the parson is on the premises of a health care agency

Question 19

Informatics

Answer 19

The science and art of turning data into information

Question 20

Information Technology (IT)

Answer 20

Refers to the management and processing of information, generally with the assistance of computers

Question 21

Interdisciplinary Care Plan

Answer 21

Disciplines involved in the patient’s care develop a care plan

Question 22

Kardex

Answer 22

Trade name for card-filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care

Question 23

Meaningful Use

Answer 23

The level of with which information technology 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

Question 24

Nursing Informatics

Answer 24

A nursing specialty that manages and communicates data, information, knowledge, and wisdom by integrating nursing computer, and information science

Question 25

Password

Answer 25

A collection of alphanumeric characters that a user types into the computer before accessing a program

Question 26

PIE Note

Answer 26

Problem-oriented medical record; the four interdisciplinary sections are the database, problem list, care plan, and progress notes

Question 27

Problem-Oriented Medical Record (POMR)

Answer 27

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

Question 28

Record

Answer 28

Written form of communication that permanently documents information relevant to health care management

Question 29

Reports

Answer 29

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

Question 30

SOAP Note

Answer 30

Progress note that focuses on a single patient problem and includes subjective and objective data, analysis, and planning; most often used in the POMR

Question 31

Standardized Care Plans

Answer 31

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

Question 32

Transfer Report

Answer 32

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