Term
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Definition
| What was the patient taking at home vs. in facility |
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Term
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Definition
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Term
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Definition
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Term
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Definition
S- Situational ( reason for calling)
B- Background (History)
A- Assessment (what you have seen, changes)
R- Recommendation |
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Term
| Guidelines for Quality Documentation and Reporting |
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Definition
- Factual
- Accurate
- Complete
- Current
- Organized
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Term
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Definition
- Episode oriented
- Key info may be lost from one episode of care to the next
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Term
| Electronic Health Record (EHR) |
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Definition
- Digital version of the patients medical record
- Integrates all the patient's info in one record
- Improves continuity of care.
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Term
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Definition
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Term
| Problem-oriented medical record (POMR) |
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Definition
- Database
- Problem List
- Care Plan
- Progress notes
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Term
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Definition
- Narrative
- Problem-oriented
- Paper
- Electronic Health Record
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Term
| Methods of Recording PROGRESS NOTES |
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Definition
- SOAP
- SOAPIE
- PIE
- DAR ( Focus charting)
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Term
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Definition
- Subjective
- Objective
- Assessment
- Plan
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Term
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Definition
- Subjective
- Objective
- Assessment
- Plan
- Intervention
- Evaluation
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Term
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Definition
- Problem
- Intervention
- Evaluation
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Term
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Definition
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Term
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Definition
- Source Records
- Charting by Exception
- Case management plan and critical pathways
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Term
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Definition
| A seperate section for each disipline |
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Term
| Charting by Exception (CBE) |
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Definition
| Focuses on charting deviations |
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Term
| Case management plan and critical pathways |
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Definition
Incorporate a multidisiplinary approach to care
variances |
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Term
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Definition
- admission nursing history form
- Flow sheets and graphic records
- Patient care summary or Kardex
- Standardized care plans
- Discharge summary forms
- Acuity Records
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Term
| Admission nursing history form |
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Definition
| Guides the nurse through a complete assessment to identify revelant nursing diagnosis and problems |
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Term
| Flow sheet and graphic records |
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Definition
| Help team memebers to quickly see patient trends over time and decrease time spent on writing narrative notes |
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Term
| Patient care summary or Kardex |
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Definition
| a portable "flip-over" file or notebook with the patient info |
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Term
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Definition
| Pre-printed, established guidelines used to care for patients who have similar health problems |
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Term
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Definition
- Occurs with tansfer of patient care
- Provides continuity and individualized care
- Reports are quick and efficient
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Term
| Telephone reports and Orders |
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Definition
- Situation-background-assessment-recommendation (SBAR)
- Document EVERY CALL
- READ BACK
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Term
| Incident or Occurrence Reports |
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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
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Term
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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)
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Term
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Definition
- Computerized clinical information systems
- Administrative information systems
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Term
| Computerized Clinical Information systems (CISs) |
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Definition
- Monitoring systems
- Order entry
- laboratory
- pharmacy systems
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Term
| Computerized provider order entry (CPOE) |
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Definition
- Improves accuracy
- speeds implementation
- improves productivity
- saves money
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