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| protection and support of another’s rights |
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| self-determination; being independent and self-governing |
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| ethics that encompass all those perspectives that seek to understand human nature and behavior, the domain of social science, and the natural world |
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| approach to bioethics that directs attention to the specific situations of individual patients viewed within the context of their life narrative |
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| branch of bioethics concerned with ethical problems that arise within the context of caring for patients |
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| principles that reflect the primary goals, values,and obligations of the profession |
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| ethical system in which actions are right or wrong independent of the consequences they produce |
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| the ability to behave in an ethical way; to do the ethically right thing because it is the right thing to do |
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| situation that arises when attempted adherence to basic ethical principles results in two conflicting courses of action |
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| occurrence when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action |
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| system dealing with standards of character and behavior related to what is right and wrong |
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| type of ethical approach that aims to critique existing patterns of oppression and domination in society,especially as these affect women and the poor |
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| keeping promises and commitments made to others |
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| process that distributes benefits, risks, and costs fairly |
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| like ethics, concerned with what constitutes right action; more informal and personal than the term ethics |
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| principle of avoiding evil |
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| a subset of bioethics; formal study of ethical issues that arise in the practice of nursing and of the analysis used by nurses to make ethical judgments |
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| an action that is based on what a parent would do |
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| an approach to bioethics that offers specific action guides |
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| action-guiding theory of ethics that states that the rightness or wrongness of an action depends on the consequences of the action |
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| set of beliefs that are meaningful in life and that influence relationships with others |
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| organization of values ranked along a continuum of importance |
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| process by which people come to understand their own values and value system |
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| process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education |
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| threat or an attempt to make bodily contact with another person without that person’s permission |
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| assault that is carried out |
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| process by which a person who has met certain criteria established by a nongovernmental association is granted recognition |
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| law resulting from court decisions that is then followed when other cases involving similar circumstances and facts arise; common law is as binding as civil law |
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| general term that refers to ways in which professional competence is maintained |
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| offense against people or property; the act is consideredto be against the government, referred to in a lawsuit as “the people,” and the accused is prosecuted by the state |
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| an intentional tort in which one party makes derogatory remarks about another that diminishes the other party’s reputation; slander is oral defamation of character; libel is written defamation of character |
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| the one being accused of a crime or tort |
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| nurse who explains to the judge and jury what happened based on the patient’s record and who offers an opinion as to whether the nursing care met acceptable standards of practice |
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| nurse who has knowledge of the actual incident prompting a legal case; bases testimony on firsthand knowledge of the incident not on assumptions |
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| (1) crime punishable by imprisonment in a state or federal penitentiary for more than 1 year; (2) crime of greater offense than a misdemeanor |
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| willful and purposeful misrepresentation that could cause, or has caused, loss or harm to people or property |
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| legal responsibility for one’s acts (and failure to act);includes responsibility for financial restitution of harms resulting from negligent acts |
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| to be given a license to practice nursing in a state or province after successfully meeting requirements |
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| act of negligence as applied to a professional person such as a physician, nurse, or dentist |
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| crime of lesser offense than a felony and punishable by fines, imprisonment (usually for less than 1 year),or both |
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| performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do |
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| person or government bringing a lawsuit against another |
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| an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof |
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| law enacted by a legislative body |
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| wrong committed by a person against another person or his property |
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| term generally used to refer to employees who report their employers’ violation of the law to appropriate lawenforcement agencies outside the employers’facilities |
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| communication method used by nurses who are completing care for a patient to transmit patientinformation to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped |
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| charting by exception (CBE) |
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| shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes |
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| critical/collaborative pathway |
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| case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions |
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| to consult with someone to exchange ideas or to seek information, advice, or instructions |
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| process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution |
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| description of where the patient stands in relation to problems identified in the record at discharge;documents any special teaching or counseling the patient received, including referrals |
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| written, legal record of all pertinent interventions with the patient—assessments, diagnoses, plans, inter-ventions, and evaluations |
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| electronic medical record (EMR) |
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| computer-based records or data that can be distributed among many caregivers in a standardized format |
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| graphic record of abbreviated aspects of patient’s condition (e.g., vital signs, routine aspects of care) |
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| a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format |
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| form used to record specific patient variables |
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| tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor |
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| a standard established by healthcare institutions that specifies the information that must be collected from every patient |
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| progress notes written by nurses in a source-oriented record |
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| specialty that integrates nursing science,computer science, and information science to manage and com-municate data, information, and knowledge in nursing practice |
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| Outcome and assessment information set (OASIS) |
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| assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home care patients and forms the basis for measuring patient outcomes for the purpose of improving the quality of care that is provided |
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| a compilation of a patient’s health information;the patient record is the only permanent legal document that details the nurse’s interactions with the patient |
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| personal health record (PHR) |
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| information sheets that contain the individual’s medical history, including diagnoses,symptoms, and medications |
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| documentation system that does not develop aseparate care plan; the care plan is incorporated into the progress notes in which problems are identified by number,worked up using the problem (P), intervention (I), evaluation(E) format, and evaluated each shift |
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| problem-oriented medical record (POMR) |
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| documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care, and progress notes |
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| any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes |
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| process of sending or guiding someone to another source for assistance |
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| consistent, clear, structured, and easy-to-use method of communication between healthcare personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations. |
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| method of charting narrative progress notes;organizes data according to subjective information (S),objective information (O), assessment (A), and plan (P) |
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| documentation system in which each healthcare group records data on its own separate form |
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| documentation method in case management that records unexpected events, the cause for the event,actions taken in response to the event, and discharge planning when appropriate |
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