Term
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Definition
| anything written or printed on which you rely as record or proof of pt actions and activities |
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Term
according to HIPAA to eliminate barriers that could delay care, providers are:
a.
b.
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Definition
a. notify pt's on their privacy policy
b. make a resonable effort to attain written acknoledgement of this notification |
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Term
| the standards of documentation by The Joint Commission require: |
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Definition
| your documentation to be within the context of the nursing process, including evidence of pt and family teaching and discharge planning |
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Term
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Definition
| means by which pt needs and progress, individual therapies, pt education, and discharge planning are conveyed to others in the health care team |
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Term
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Definition
| describes exactly what happens to the pt and must follow agency standards |
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Term
| Diagnostic related groups |
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Definition
| DRG's is a classification system based on pt's medical diagnosis that supports reimbursement |
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Term
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Definition
| learning the nature of the illness and the individuals responses |
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Term
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Definition
| gathering of statistical data of clinical disorders, complications, therapies, recovery, and deaths |
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Term
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Definition
| objective, ongoing reviews to determine the degree to which quality improvement standards are met |
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Term
five important guidelines must be followed to ensure quality documentation and reporting:
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Definition
a. factual
b. accurate
c. complete
d. current
e. organized |
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Term
| which method of documentation is: story like format that has the tendency to have repititious information and be time consuming |
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Definition
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Term
| which method of documentation is: database, problem list, care plan, and progress notes |
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Definition
| problem oriented medical record |
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Term
| which method of documentation is: subjective, objective, assessment, plan |
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Definition
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Term
| which method of documentation is: SOAP with intervention and evaluation added |
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Definition
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Term
| which method of documentation is: problem, intervention, and evaluation with a nursing orgin |
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Definition
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Term
| which method of documentation is: electronic record of pt information generated whenever a pt accesses medical care in any health care setting |
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Definition
| Electronic Health Record EHR |
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Term
| which method of documentation is: seperate section for each discipline |
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Definition
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Term
| which method of documentation is: focuses on deviations from the established norm or abnormal findings; highlights trends and changes |
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Definition
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Term
| which method of documentation is: incorporates a multidisciplinary approach to documenting pt care |
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Definition
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Term
| which method of documenting is: multidisciplinary care plans that include pt problems, key interventions, and expected outcomes |
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Definition
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Term
| common record keeping forms: provides baseline data to compare with changes in the pt's condition |
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Definition
| admission nursing hx forms |
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Term
| common record keeping forms: provides current info that is accessible to all members of the health care team |
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Definition
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Term
| common record keeping forms: has activity, treatment, and nursing care plan sections that organize information for quick reference |
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Definition
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Term
| common record keeping forms: level is based on the type and number of nursing interventions required over a 24 hour period |
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Definition
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Term
| common record keeping forms: preprinted, established guidelines used to care for the pt |
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Definition
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Term
| common record keeping forms: includes medications, diet, community resources, and follow up care |
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Definition
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Term
| Nursing informatics integrates |
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Definition
| nursing science, computer science and information science to manage and communicate data, information and knowledge |
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