Shared Flashcard Set

Details

Documentation and Informatics
Chapter 26
29
Nursing
Undergraduate 2
11/09/2012

Additional Nursing Flashcards

 


 

Cards

Term
define documentation
Definition
anything written or printed on which you rely as record or proof of pt actions and activities
Term

according to HIPAA to eliminate barriers that could delay care, providers are:

 

a.

b.

 

Definition

a. notify pt's on their privacy policy

b. make a resonable effort to attain written  acknoledgement of this notification

Term
the standards of documentation by The Joint Commission require:
Definition
your documentation to be within the context of the nursing process, including evidence of pt and family teaching and discharge planning
Term
Communication
Definition
means by which pt needs and progress, individual therapies, pt education, and discharge planning are conveyed to others in the health care team
Term
Legal Documentation
Definition
describes exactly what happens to the pt and must follow agency standards
Term
Diagnostic related groups
Definition
DRG's is a classification system based on pt's medical diagnosis that supports reimbursement
Term
Education
Definition
learning the nature of the illness and the individuals responses
Term
research
Definition
gathering of statistical data of clinical disorders, complications, therapies, recovery, and deaths
Term
auditing
Definition
objective, ongoing reviews to determine the degree to which quality improvement standards are met
Term

five important guidelines must be followed to ensure quality documentation and reporting:

 

Definition

a. factual

b. accurate

c. complete

d. current

e. organized

Term
which method of documentation is: story like format that has the tendency to have repititious information and be time consuming
Definition
Narrative
Term
which method of documentation is: database, problem list, care plan, and progress notes
Definition
problem oriented medical record
Term
which method of documentation is: subjective, objective, assessment, plan
Definition
SOAP
Term
which method of documentation is: SOAP with intervention and evaluation added
Definition
SOAPIE
Term
which method of documentation is: problem, intervention, and evaluation with a nursing orgin
Definition
PIE
Term
which method of documentation is: electronic record of pt information generated whenever a pt accesses medical care in any health care setting
Definition
Electronic Health Record EHR
Term
which method of documentation is: seperate section for each discipline
Definition
source record
Term
which method of documentation is: focuses on deviations from the established norm or abnormal findings; highlights trends and changes
Definition
charting by exception
Term
which method of documentation is: incorporates a multidisciplinary approach to documenting pt care
Definition
case management
Term
which method of documenting is: multidisciplinary care plans that include pt problems, key interventions, and expected outcomes
Definition
critical pathways
Term
common record keeping forms: provides baseline data to compare with changes in the pt's condition
Definition
admission nursing hx forms
Term
common record keeping forms: provides current info that is accessible to all members of the health care team
Definition
flow sheets
Term
common record keeping forms: has activity, treatment, and nursing care plan sections that organize information for quick reference
Definition
Kardex
Term
common record keeping forms: level is based on the type and number of nursing interventions required over a 24 hour period
Definition
acutity records
Term
common record keeping forms: preprinted, established guidelines used to care for the pt
Definition
standarized care plans
Term
common record keeping forms: includes medications, diet, community resources, and follow up care
Definition
discharge summary forms
Term
Nursing informatics integrates
Definition
nursing science, computer science and information science to manage and communicate data, information and knowledge
Supporting users have an ad free experience!