Chapter 9 Recording and Reporting Key Terms Flashcards
inspectors who examine client records, survey medical records to determine whether the care provided meets the established criteria for reimbursement.
Auditors
an exemption whereby an agency can release private health information without a client’s prior authorization
beneficial disclosures
change-of-shift report
a binder or folder that promotes the orderly collection, storage, and safekeeping of a person’s medical record.
chart
process of entering information
charting
documentation method in which only abnormal assessment findings or care that deviates from the standard is charted
charting by exception
form of documentation in which the nurse indicates with a check mark or initials that routine care has been performed
checklist
process of promoting care that reflects established agency standards
continuous quality improvement
the process of entering information
documenting
repetitious entry of the same information in the medical record
double charting
documenting client information with a computer
electronic charting
form of documentation that contains sections for recording frequently repeated assessment data
flow sheet
Focus charting follows a DAR model (D = data, A = action, R = response). DAR notations tend to reflect the steps in the nursing process.
focus charting
legislation that sets national standards for the security of health information, ensures that an individual’s electronic, paper, or oral health information is protected
Health Insurance Portability and Accountability Act (HIPAA)
collection, storage, retrieval, and sharing of recorded data
informatics
quick reference for current information about the client and the client’s care
Kardex
is a collection of information about a person’s health, the care provided by health care providers, and the client’s progress.
medical record
time based on a 24-hour clock
military time
portions or isolated pieces of information necessary for an immediate purpose
minimum disclosure
style of documentation generally used in source-oriented records
narrative charting
written assignments on a standardized worksheet that contains a column for nursing diagnoses, outcome criteria, nursing interventions, and their rationale for each assigned client
nursing care plan
method of recording the client’s progress under the headings of problem, intervention, and evaluation
PIE charting
records organized according to the client’s health problems
problem-oriented record
process of promoting care that reflects established agency standards
quality assurance
process of writing information
recording
visits to clients on an individual basis or as a group
rounds
model for effective communication identifying situation, background, assessment, and recommendation
SBAR format
documentation style more likely to be used in a problem-oriented record
SOAP charting
records organized according to the source of information
source-oriented record
an agency’s internal process for self-improvement to ensure that the level of care reflects or exceeds established standards.
total quality improvement
time based on two 12-hour revolutions on a clock
traditional time
