Shared Flashcard Set

Details

Chpt 15. Documenting and Reporting
Vocabulary
17
Nursing
Not Applicable
01/11/2010

Additional Nursing Flashcards

 


 

Cards

Term
Change-of-Shift Report
Definition
a report given to nurses on the next shift
Term
Chart/Client Record
Definition
a formal, legal document that provides evidence of a client's care
Term
Charting/Documenting
Definition
the process of making an entry on a client record
Term
Charting by Exception (CBE)
Definition
a documentation system in which only significant findings or exceptions to norms are recorded
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
Flow Sheet
Definition
a record of the progress 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
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) / Problem-oriented record(POR)
Definition
13. Problem-oriented medical record (POMR) data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
Term
Progress Notes
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/Documenting
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 separate section or sections of the client's chart
Supporting users have an ad free experience!