Term
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Definition
| Any information a subject relates will not be made public or available to others without the subject's consent. |
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Term
| Source-Oriented Clinical Record |
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Definition
| A record in which each person/department makes notations in a separate area of the record. |
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Term
| Problem-Oriented Medical Record |
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Definition
| Client data are recorded and arranged according to the client's problems. |
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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
| An acronym for a charting method that follws a recording sequence of problem, intervention and evaluation of the effectiveness of interventions. |
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Term
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Definition
| A documentation system in which only significant findings or exceptions to norms are recorded. |
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Term
| Computer-Based Client Records |
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Definition
| Electronic client data retrievable by caregivers and other person who require the data. |
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Term
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Definition
| A method for delivering nursing care in which the nurse is responsible for a caseload of clients across the health care continuum. |
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Term
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Definition
| Trade name for a method using a series of cards to organize and record client data and instructions for daily care. |
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Term
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Definition
| Chart entries made by all health professionals involved in patient care for the purpose of describing client problems, treatments and progress toward desired outcomes. |
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Term
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Definition
| A record of the progress of data, often charted in graph form. |
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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
| The process of anticipating and planning for client needs after discharge. |
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Term
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Definition
| The skills an learning commonly possessed by members of a profession. |
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Term
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Definition
| A predetermined and preprinted plan specifying the procedure to be follwoed in a particular situation. |
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Term
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Definition
| Rules to govern the handling of frequently occurring situations. |
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Term
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Definition
| Formal plan that specifies the nursing care for groups of clients with common needs. |
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Term
| Nursing Outcomes Classification-NOC |
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Definition
| A taxonomy for describing client outcomes that respond to nursing interventions. |
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Term
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Definition
| The process of establishing a preferential order for nursing startegies. |
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Term
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Definition
| Desired outcome-Describe in terms of observable client responses what the nurse hopes to achive by implementing nursing interventions. |
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Term
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Definition
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Term
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Definition
| Any treatment that a nurse performs to enhance client outcomes, based on clinical judgment and knowledge. |
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Term
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Definition
| Intellectual skills that include problem-solving, decision-making, critical thinking and creativity. |
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Term
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Definition
| All verbal and nonverbal activities people use when communicationg directly with one another. |
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Term
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Definition
| Hands-on skills such as those required to manipulate equipment or administer injections. |
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Term
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Definition
| The transfer of responsibility for the performance of an activity froem one person to another while retaining accountability for the outcome. |
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