Chapter 26: Documentation and Informatics Flashcards
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?
Accreditation
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?
Acuity records
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?
Case management
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?
Charting by exception (CBE)
This is a computerized program used within the healthcare setting to support decisions making. What is this defined as?
Clinical decision support system (CDSS)
The process of entering medication orders or other physician instructions electronically instead of on paper charts. What is this defined as?
Computerized provider order entry (CPOE)
This occurs when one professional caregiver gives formal advice about the care of a patient to another caregiver. What is this defined as?
Consultations
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?
Critical pathways
This is a format used in focus charting for recording patient information.
What is this defined as?
DAR
Group of patients classified to establish a mechanism for health care reimbursement based on length of stay.
What is this defined as?
Diagnosis-related group (DRG)
This is anything written or printed on which you rely as record or proof of patient actions and activities. What is this defined as?
Documentation
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?
Electronic health record (EHR)
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?
Electronic medical record (EMR)
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?
Firewall
Documents on which frequent observations or specific measurements are recorded. What is this defined as?
Flow sheets
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?
Focus charting
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?
Diagnosis-Related Group (DRG)
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?
Critical Pathways
The use of this system can help reduce errors related to poor handwriting or transcription of medication orders. What is this defined as?
Computerized Provider Order Entry (CPOE)
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?
Clinical Decision Support System (CDSS)
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?
Charting by exception (CBE)
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?
Case Management
