Chapter 26: Documentation and Informatics

Question 1

This is a process whereby a professional association or nongovernmental agency grants recognition to a school or institution for demonstrated ability to meet predetermined criteria. What is this defined as?

Answer 1

Accreditation

Question 2

This is not part of a patient’s medical record but they are useful for determining the hours of care and staff required for a given group of patients and the patient’s care needs What is this defined as?

Answer 2

Acuity records

Question 3

This is a system for delivering healthcare to an individual patient or group of patients across an episode of illness and/ or a continuum of care. What is this defined as?

Answer 3

Case management

Question 4

This charting methodology in which data are entered only when there is an exception from that which is normal or expected. What is this defined as?

Answer 4

Charting by exception (CBE)

Question 5

This is a computerized program used within the healthcare setting to support decisions making. What is this defined as?

Answer 5

Clinical decision support system (CDSS)

Question 6

The process of entering medication orders or other physician instructions electronically instead of on paper charts. What is this defined as?

Answer 6

Computerized provider order entry (CPOE)

Question 7

This occurs when one professional caregiver gives formal advice about the care of a patient to another caregiver. What is this defined as?

Answer 7

Consultations

Question 8

Tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. What is this defined as?

Answer 8

Critical pathways

Question 9

This is a format used in focus charting for recording patient information.
What is this defined as?

Answer 9

DAR

Question 10

Group of patients classified to establish a mechanism for health care reimbursement based on length of stay.
What is this defined as?

Answer 10

Diagnosis-related group (DRG)

Question 11

This is anything written or printed on which you rely as record or proof of patient actions and activities. What is this defined as?

Answer 11

Documentation

Question 12

This is part of the electronic health record that contains patient data gathered in a healthcare setting at a specific time and place. What is this defined as?

Answer 12

Electronic health record (EHR)

Question 13

This an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. What is this defined as?

Answer 13

Electronic medical record (EMR)

Question 14

This is a combination of hardware and software that protects private network resources from outside hackers, network damage and theft or misuse of information. What is this defined as?

Answer 14

Firewall

Question 15

Documents on which frequent observations or specific measurements are recorded. What is this defined as?

Answer 15

Flow sheets

Question 16

This charting methodology for structuring progress notes according to the focus of the note (e. g., symptoms and nursing diagnosis). Each note includes data, actions, and patient response. What is this defined as?

Answer 16

Focus charting

Question 17

This classification is based on the following variables: primary and secondary diagnosis, co-morbidities, primary and secondary procedures, and age. What is this defined as?

Answer 17

Diagnosis-Related Group (DRG)

Question 18

This is designed for a specific care type, it is also used to manage the care of a patient throughout a projected length of stay. What is this defined as?

Answer 18

Critical Pathways

Question 19

The use of this system can help reduce errors related to poor handwriting or transcription of medication orders. What is this defined as?

Answer 19

Computerized Provider Order Entry (CPOE)

Question 20

This system is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information to the user. What is this defined as?

Answer 20

Clinical Decision Support System (CDSS)

Question 21

This charting methodology reduces time spent documenting in charting. It is a shorthand method for documenting normal findings and routine care. What is this defined as?

Answer 21

Charting by exception (CBE)

Question 22

This includes assessment and development of a plan of care, coordination of all services, referral, and follow-up; usually assigned to one professional. What is this defined as?

Answer 22

Case Management