Chapter 10: Informatics and Documentation; Key Terms Flashcards
Accreditation
Process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet a predetermined criteria
Acuity Recording
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
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
Change of Shift Report
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 times 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.
A process by which the health care directly enters orders for patient care into the hospital information system
Confidentiality
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 the following variables; primary and secondary diagnosis, comorbidities, primary and secondary procedures, and age
Documentation
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
Firewall
Combination of hardware and software that protects private network resources
Flow Sheets
Documents on which frequent observations or specific measurements are recorded
Focus Charting
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
Graphic Record
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
Hands-Off Report
Anytime one health care provider transfers care of a patient to another health care provider
Health Care Information System (HIS)
A group of systems used within a health care enterprise that support and enhance health care
Incident (Occurrence of Event) Report
Confidential document that describes any patient accident while the parson is on the premises of a health care agency
Informatics
The science and art of turning data into information
Information Technology (IT)
Refers 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
Kardex
Trade name for card-filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care
Meaningful Use
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
Nursing Informatics
A nursing specialty that manages and communicates data, information, knowledge, and wisdom by integrating nursing computer, and information science
Password
A collection of alphanumeric characters that a user types into the computer before accessing a program
PIE Note
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
Record
Written form of communication that permanently documents information relevant to health care management
Reports
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
SOAP Note
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
Transfer Report
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
