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Fundamentals of Nursing (Kozier 9e)
Ch. 15 Documenting and Reporting
21
Nursing
Not Applicable
09/09/2012

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Cards

Term
Change-of-shift Report
Definition
a report given to nurses on the next shift
Term
Chart
Definition
a formal, legal document that provides evidence of a client's care
Term
Charting by Exception (CBE)
Definition
a documentation system in which only significant findings or exceptions to norms are recorded
Term
Client Record
Definition
SEE Chart
Term
Discussion
Definition
an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
Term
Documenting
Definition
the process of making an entry on a client record; charting, recording
Term
Flow Sheet
Definition
a record of the proggress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form
Term
Focus Charting
Definition
a method of charting that uses key words or foci to describe what is happening to the client
Term
Handoff Communication
Definition
Term
Kardex
Definition
the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care - especially care that changes frequently and must be kept up to date
Term
Narrative Charting
Definition
a descriptive record of client data and nursing interventions, written in sentences and paragraphs
Term
PIE
Definition
an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
Term
Problem-oriented Medical Record (POMR)
Definition
data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
Term
Problem-oriented Record (POR)
Definition
SEE Problem-oriented Medical Record
Term
Progress Note
Definition
chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes
Term
Record
Definition
a written communication providing formal, legal documentation of a client's progress
Term
Recording
Definition
the process of making written entries about a client on the medical record
Term
Report
Definition
whether oral or written,it should be concise, including pertinent information but no extraneous detail
Term
SOAP
Definition
an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning
Term
Source-oriented Record
Definition
a record in which each person or department makes notations in a seperate section or sections of the client's chart
Term
Variance
Definition
a variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame
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