Shared Flashcard Set

Details

Documentation and Informatics
Documentation and informatics
33
Nursing
Professional
09/20/2013

Additional Nursing Flashcards

 


 

Cards

Term
Medication reconcilation
Definition
What was the patient taking at home vs. in facility
Term
T.O.
Definition
Telephone Order
Term
V.O.
Definition
Verbal order
Term
SBARR
Definition

S- Situational ( reason for calling)

B- Background (History)

A- Assessment (what you have seen, changes)

R- Recommendation 

Term
Guidelines for Quality Documentation and Reporting
Definition
  • Factual 
  • Accurate
  • Complete
  • Current 
  • Organized
Term
Paper Record
Definition
  • Episode oriented
  • Key info may be lost from one episode of care to the next
Term
Electronic Health Record (EHR)
Definition
  • Digital version of the patients medical record
  • Integrates all the patient's info in one record
  • Improves continuity of care.
Term
Narrative
Definition
The traditional method
Term
Problem-oriented medical record (POMR)
Definition
  • Database 
  • Problem List
  • Care Plan
  • Progress notes
Term
Methods of RECORDING
Definition
  • Narrative
  • Problem-oriented
  • Paper
  • Electronic Health Record
Term
Methods of Recording PROGRESS NOTES
Definition
  • SOAP
  • SOAPIE
  • PIE
  • DAR ( Focus charting)
Term
SOAP
Definition
  • Subjective
  • Objective
  • Assessment
  • Plan
Term
SOAPIE
Definition
  • Subjective 
  • Objective
  • Assessment
  • Plan
  • Intervention
  • Evaluation
Term

PIE

 

Definition
  • Problem 
  • Intervention
  • Evaluation
Term
Focus Charting
Definition
  • Data
  • Action
  • Response
Term
Methods of REPORTING
Definition
  • Source Records
  • Charting by Exception
  • Case management plan and critical pathways
Term
Source Records
Definition
A seperate section for each disipline
Term
Charting by Exception (CBE)
Definition
Focuses on charting deviations
Term
Case management plan and critical pathways
Definition

Incorporate a multidisiplinary approach to care

variances

Term
Record- Keeping Forms
Definition
  • admission nursing history form
  • Flow sheets and graphic records
  • Patient care summary or Kardex
  • Standardized care plans
  • Discharge summary forms
  • Acuity Records
Term
Admission nursing history form
Definition
Guides the nurse through a complete assessment to identify revelant nursing diagnosis and problems
Term
Flow sheet and graphic records
Definition
Help team memebers to quickly see patient trends over time and decrease time spent on writing narrative notes
Term
Patient care summary or Kardex
Definition
a portable "flip-over" file or notebook with the patient info
Term
Standardized care plans
Definition
Pre-printed, established guidelines used to care for patients who have similar health problems
Term
Hand off Report
Definition
  • Occurs with tansfer of patient care
  • Provides continuity and individualized care
  • Reports are quick and efficient
Term
Telephone reports and Orders
Definition
  • Situation-background-assessment-recommendation (SBAR)
  • Document EVERY CALL
  • READ BACK

 

Term
Incident or Occurrence Reports
Definition
  • Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
  • Follow agency policy
Term
Health informatics
Definition
  • Application of computer and info science for managing health-related data
  • Focus on the patient and the process of care
  • Goal is to enhance the quality and efficiency of care provided.
  • Driven by the Health information Technology for Econmic and Clinical Health Act (HITECH)
Term
Nursing Informatics
Definition
  • Computerized clinical information systems 
  • Administrative information systems
Term
Computerized Clinical Information systems (CISs)
Definition
  • Monitoring systems 
  • Order entry
  • laboratory
  • pharmacy systems
Term
Computerized provider order entry (CPOE)
Definition
  • Improves accuracy
  • speeds implementation
  • improves productivity
  • saves money
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