Term
|
Definition
info that is monitored over time
ex.
vitals, I&O, glucose |
|
|
Term
|
Definition
Mar medication administration record
Mrr medication reconciliation record |
|
|
Term
| source oriented recording |
|
Definition
separate sections for each discipline
data is fragmented difficult to track
hard to see trends |
|
|
Term
| problem oriented recording |
|
Definition
organized around patients problems
facilitates collaborations |
|
|
Term
|
Definition
only chart abnormal findings
advantages: see trends
does not address wellness |
|
|
Term
|
Definition
specific to patients and diagnosis
based on evidence based practice
defines delivery of care based on protocols |
|
|
Term
|
Definition
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLANNING |
|
|
Term
|
Definition
SUBJECTIVE
OBJECTIVE
ASSMESSMENT
PLANNING
IMPLEMENTATION
EVALUATION
REASSESS |
|
|
Term
|
Definition
PROBLEM
INTERVENTION
EVALUATION |
|
|
Term
|
Definition
|
|
Term
|
Definition
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATION |
|
|
Term
| what to include in report when changing shifts |
|
Definition
patient identification
active problem list
past medical info
current condition
allergies
code status
psychological concerns
anticipated events |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
