Term
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Definition
| is the written or typed legal record of all pertinent interactions with the patient-assessing, diagnosing, planning, implementing, and evaluating. |
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Term
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Definition
| Is a compilation of a patient's health information. |
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Term
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Definition
| Is one which each healthcare group keeps data on its own seperate form. ex: one section for dr.'s, nurses, physical therapists etc... |
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Term
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Definition
| Notes written to inform the caregivers of the progress a patient is making toward achieving expected outcomes. |
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Term
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Definition
| Progress notes written by nurses in a source-orientated record. |
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Term
Problem-Oriented Medical Record
(POMR) |
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Definition
| or problem oriented record. The POMR is organized around a patient's problems rather than around sources of information. |
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Term
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Definition
| (Subjective data, Objective data, Assessment (the caregiver's judgment about the situation), Plan.) is used to organize data enteries in the progress notes of the POMR. |
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Term
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Definition
| system is unique in that it does note develop a seperate plan of care. The plan of care is incorporated into the progress notes in which problems are identified by number (in the order they are identified). |
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Term
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Definition
| is to bring the focus of care back to the patient and the patient's concerns. |
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Term
Charting By Exception
(CBE) |
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Definition
| is a shorthand documentation method that makes use of well-definded standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. |
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Term
Collaborative Pathways
AKA: CRITICAL PATHWAYS
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Definition
| are used in case management model. The collaborative pathway specifies the plan of care linked to expected outcomes along a timeline. |
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Term
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Definition
| is the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate. |
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Term
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Definition
| A key to component to facilitate data and outcome comparisons. These specific categories of information will use uniform definitions to create a common language among multiple health care data users. |
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Term
Electronic Medical Records
(EMR) |
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Definition
| These data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily. |
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Term
Personal Health Records
(PHRs) |
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Definition
| on the web to manage their healthcare via computer. |
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Term
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Definition
| are documentation tools used to record routine aspects of nursing care. |
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Term
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Definition
| Is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characterisitcs. |
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Term
OASIS
outcome and assessment information set |
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Definition
is a group of data elements that :
- Represent core items of a comprehensive assessment fir an adult home care patient
- Form the basis for meauring patient outcomes for purposes of outcome-based quality improvement (OBQI)
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Term
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Definition
| should be written that concisely summarizes the reasons for treatment, significant findings, the procedures performed and the treatment rendered, the patient's condition on dischargeor transfer, and any specific pertinent instructions given to the patient and family. |
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Term
SBAR Communication
(situation, background, assessment, recommendation)
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Definition
| technique as a framework for communication between members of the healthcare team about a patients condition. |
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Term
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Definition
| is given by the primary nurse to the nurse replacing him or her by the charge nurse to the nurse who assumes responsibility for continuing care of the patient. |
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Term
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Definition
| also termed variance or occurrence report, is a tool used by healthcare agencies to documentthe occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor. |
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Term
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Definition
| is to council with someone to exhange ideas or to seek information, advice, or instructions. |
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Term
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Definition
| The process of inviting another professional to evaluate the patient and make recommendations to you about hir or her treatment. |
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Term
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Definition
| The process of sending or guiding the patient to another source for assistance. |
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Term
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Definition
| is a speciality that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. |
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