Term
| purpose of documenting (charting) |
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Definition
| communication, planning patient care, auditing health agencies, research, education, reimbursement, legal issues, health care analysis |
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Term
| American Nurses Association |
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Definition
| The nurse has a duty to maintain confidentialty of all patient information |
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Term
Health Insurance Portability & Accountability Act
(HIPAA) |
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Definition
| ensures privacy and confidentiality of protected health information |
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Term
| charting by exception (CBE) |
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Definition
| only document "out of the ordinary" |
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Term
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Definition
comprehensive assessment; referred to as initial database, nursing history, nursing assessment;
completed when patient is admitted to the hospital |
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Term
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Definition
| JCAHO, traditional care plan, standardized care plan |
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Term
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Definition
| requires evidence of a current nursing care plan |
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Term
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Definition
| individualized care plan written for each patient |
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Term
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Definition
| nursing plan of care for a group of patients with the same problem |
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Term
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Definition
concise method of organizing and recording data;
info can be accessed quickly;
if nurse needs to know activity level, can look here
usually contains allergies, list of meds, IV fluids, changes, labs completed |
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Term
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Definition
pre-printed document allows nurse to record data quickly and concisely;
ex include graphic flow sheets, I & O record, medication administration record |
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Term
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Definition
| provides info about patients progress |
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Term
| characteristics of effective documentation |
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Definition
| consistent with professional and agency standards, complete, concise, accurate, factual, organized, timely, confidential |
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