Shared Flashcard Set

Details

AH1 Nursing Process: Documenting and Reporting
N/A
13
Nursing
Undergraduate 1
01/21/2013

Additional Nursing Flashcards

 


 

Cards

Term
purpose of documenting (charting)
Definition
communication, planning patient care, auditing health agencies, research, education, reimbursement, legal issues, health care analysis
Term
American Nurses Association
Definition
The nurse has a duty to maintain confidentialty of all patient information
Term

Health Insurance Portability & Accountability Act

(HIPAA)

Definition
ensures privacy and confidentiality of protected health information
Term
charting by exception (CBE)
Definition
only document "out of the ordinary"
Term
admission assessment
Definition

comprehensive assessment; referred to as initial database, nursing history, nursing assessment;

completed when patient is admitted to the hospital

Term
Nursing care plans
Definition
JCAHO, traditional care plan, standardized care plan
Term
JCAHO
Definition
requires evidence of a current nursing care plan
Term
traditional care plan
Definition
individualized care plan written for each patient
Term
standardized care plan
Definition
nursing plan of care for a group of patients with the same problem
Term
Kardex
Definition

concise method of organizing and recording data;

info can be accessed quickly;

if nurse needs to know activity level, can look here

usually contains allergies, list of meds, IV fluids, changes, labs completed

Term
Flow sheets
Definition

pre-printed document allows nurse to record data quickly and concisely; 

ex include graphic flow sheets, I & O record, medication administration record

Term
progress note
Definition
provides info about patients progress
Term
characteristics of effective documentation
Definition
consistent with professional and agency standards, complete, concise, accurate, factual, organized, timely, confidential
Supporting users have an ad free experience!