Term
| admit note/admission note |
|
Definition
| the first nurse's note acknowledging the arrival of a new client |
|
|
Term
|
Definition
| the acronym that stands for assessment, problem identification, interventions and evaluation |
|
|
Term
|
Definition
| provides documentation in progress notes only if data are significant or abnormal |
|
|
Term
| computerized provider order entry (CPOE) |
|
Definition
| direct electronic documentation of orders by health care providers into a clinical information system that are routed to the appropriate clinical area for action |
|
|
Term
| critical or clinical pathways (care maps) |
|
Definition
| may be recorded using an interdisciplinary approach or organized by health care discipline |
|
|
Term
|
Definition
| an interdisciplinary note that reflects the circumstances surrounding the release of a client problems or needs and includes a column that summarizes the focus of the entry |
|
|
Term
|
Definition
| recording of information relevant to assessment, planning, implementation, and evaluation (client response) as a legal record that is permanent and retrievable for future purposes |
|
|
Term
| electronic health record (EHR) |
|
Definition
| a computerized account of a client's health information across several episodes of care and different facilities |
|
|
Term
| electronic medication administration records eMAR |
|
Definition
| a computerized version of a medication administration record |
|
|
Term
|
Definition
| forms used to document data that can be more easily followed in graphic or tabular form |
|
|
Term
| interval or progress note |
|
Definition
| interdisciplinary notes entered at various times during a shift that reflect any aspect of change in client condition, or anything affecting the client such as tests, STAT or prn medications, and procedures |
|
|
Term
|
Definition
| a method of charting that provides information in the form of statements that describe events surrounding client care |
|
|
Term
| problem-oriented medical records |
|
Definition
| a form of documentation originally designed to organize information according to identified client problems, with all members of the health care team documenting information sequentially |
|
|
Term
|
Definition
| a format of charting used to record progress notes with problem-focused charting; it includes subjective data, objective data, assessment, and plan |
|
|
Term
|
Definition
| a nursing note that reflects the movement of a client from one unit to another within the agency or to another agency |
|
|
