Term
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Definition
| a report given to nurses on the next shift |
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Term
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Definition
| a formal, legal document that provides evidence of a client's care |
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Term
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Definition
| the process of making an entry on a client record |
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Term
| Charting by Exception (CBE) |
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Definition
| a documentation system in which only significant findings or exceptions to norms are recorded |
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Term
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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 |
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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 |
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Term
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Definition
| a method of charting that uses key words or foci to describe what is happening to the client |
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Term
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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 |
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Term
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Definition
| a descriptive record of client data and nursing interventions, written in sentences and paragraphs |
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Term
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Definition
| an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions |
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Term
| Problem-oriented medical record(POMR) / Problem-oriented record(POR) |
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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 |
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Term
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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 |
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Term
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Definition
| a written communication providing formal, legal documentation of a client's progress |
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Term
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Definition
| the process of making written entries about a client on the medical record |
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Term
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Definition
| whether oral or written, it should be concise, including pertinent information but no extraneous detail |
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Term
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Definition
| an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning |
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Term
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Definition
| a record in which each person or department makes notations in a separate section or sections of the client's chart |
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