Fundamentals 7, 8, 10 Flashcards
Documentation that tracks variances from the clinical pathway
Case management system charting
Documentation of the nursing process, treatment, and associated care
charting
Documentation that focuses on deviations from predefined norms, using preset protocols and standards of care
charting by exception
Documentation in which data are input via the computer
computer-assisted charting
The entering of provider orders into the medical record via computer
Computerized provider order entry (CPOE)
Health record entered into a computer’s software program that is updated via the computer
electronic health record (EHR)
Documentation that centers on the patient from a positive perspective; this form of documentation has three components: data, action, and response
focus charting
Paper or electronic record that contains all orders, tests, treatments, and care that occurred during the time a person was under the care of a health care provider
medical record
method of documentation in which “P” means problem identification, “I” means interventions, and “E” means evaluation
PIE charting
Documentation that focuses on patient status, emphasizes the problem-solving approach to patient care, and provides a method for communication what, when, and how things are to be done to meet the patient’s needs
Problem-oriented medical record (POMR) charting
Documentation that is organized by the “source” or author of the documentation
Source–oriented (narrative) charting
Difficulty expressing or understanding language
aphasia
Technique for communication between members of the health care team; the acronym stands for Introduction, Situation, Background, Assessment, Recommendation, and Readback
ISBAR-R
Recognizing the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s values, needs, and preferences
patient-centered care
Communication that promotes understanding between the sender and the receiver
Therapeutic communication
Leadership style of tight control and unlimited power
autocratic
Leadership style practicing social equality or majority rule
democratic
Leadership style that is based on noninterference with what others desire
Laissez-faire
Encourages patient to continue or elaborate
General leads