KEY TERMS Flashcards
Chart health care record
Is a legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems
Charting, recording, documentation
The process of adding information to the chart
Electronic health record and electronic medical record
An electronic patient record designed for health information exchange between facilities
Assessment. A Diagnosis. D Planning P Implementation. I Evaluation. E
A)History and physical examination, medical records
D) nursing judgment
P) patient care plan
I) progress notes, patient rounds
E) diagnostic test results, physical assessment
Auditors
People appointed to examine patient charts and health records to assess qualify of care
Peer review
An appraisal by professional coworkers of equal status
Quality assurance, assessments,and improvement
An audit in health care that evaluates services provided and the results achieved compared with accepted standards
Diagnosis related groups (DRG)
System that classifies patients by age,diagnosis,surgical procedure, and other information with hundreds of different categories
Nursing notes
The form on the patients chart on which nurses record their observations, the care given, and the patient’s responses
Point of care (POC)
Computer electronic health record systems that are located at the patients bedside
Computer on wheels (COWS)
Point of cave systems housed on wheeled carts
Nomenclature
A classified system of technical or scientificnames and terminology
Informatics
The study of information processing
Personal health record(phr)
Is an extension of the EHR that allows patients to input their information into an electronic database
SBARR
The joint of commission
Situation, background,asseanssment, recommendation,read back
Is a method of communication among health care workers and part of documentation
Traditional block chart
Patient chart broken down into sections:
admission information, physicians orders, progress notes, history and physical examination data, nurses admission information, care plan and nursing notes, graphics, laboratory and X-ray examination reports.
Narrative charting
Recording of patient care in descriptive form
Problem oriented medical record(POMR)
Is organized according to the scientific problem solving system or method
Database
Large store or bank or information, as in forming the patient’s nursing diagnosis
Problem list
Active, inactive,potential,resolved problems serves as the index for chart documentation
SOAPIER subjective Objective Assessment Plan Intervention Evaluation Revision
Subjective: reported the patient
Objective: acquired by inspection
Assessment: cause of the patient’s problem
Plan: action to be taken
Intervention: specific care or action taken
Evaluation: appraisal of the response
Revision: includes changes to original plan
Charting by exception
Recording only new data or changes in patients status or care
Kardex (or RAND)
System is used by some facilities to consolidate patient orders and care needs in a centralized, concise way
Nursing care plan
Outlines the proposed nursing care based on the nursing assessment and the identified patient problems to provide continuity of care
