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
