Term
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Definition
| A visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows. |
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Term
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Definition
| Thinking that results in the development of new ideas and products. |
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Term
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Definition
| A set of questions one can apply to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas. |
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Term
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Definition
| A cognitive process that includes creativity, problem solving, and decision making. |
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Term
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Definition
| The process of establishing criteria by which alternative courses of action are developed and selected. |
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Term
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Definition
| Making specific observations from a generalization. |
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Term
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Definition
| Making generalizations from specific data. |
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Term
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Definition
| The understanding or learning of things without the conscious use of reasoning. |
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Term
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Definition
| A systematic rational method of planning and providing nursing care. |
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Term
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Definition
| Obtaining information that clarifies the nature of the problem and suggests possible solutions. |
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Term
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Definition
| A technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. |
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Term
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Definition
| A number of approaches are tried until a solution is found. |
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Term
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Definition
| The process of collecting, organizing, validating, and recording data (information) about a client's health status. |
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Term
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Definition
| Proceeding in the direction from head to toe. |
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Term
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Definition
| Restrictive question requiring only a short answer. |
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Term
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Definition
| Any piece of information or data that influences decisions. |
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Term
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Definition
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Term
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Definition
| All information about a client, includes nursing health history and physical assessment, physician's history, physical examination, and laboratory and diagnostic test results. |
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Term
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Definition
| A highly structured interview that uses closed questions to elicit specific information. |
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Term
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Definition
| Interpretations or conclusions made based on cues or observed data. |
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Term
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Definition
| A planned communication; a conversation with a purpose. |
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Term
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Definition
| A question that influences the client to give a particular answer. |
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Term
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Definition
| A question that does not direct or pressure a client to answer in a certain way. |
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Term
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Definition
| An interview using open-ended questions and empathetic responses to build rapport and learn client concerns. |
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Term
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Definition
| A systematic rational method of planning and providing nursing care. |
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Term
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Definition
| (signs) Information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled. |
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Term
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Definition
| Questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic? |
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Term
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Definition
| A relationship between two or more people of mutual trust and understanding. |
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Term
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Definition
| (screening examination) A brief review of essential functioning of various body parts or systems. |
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Term
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Definition
| (review of systems) A brief review of essential functioning of various body parts or systems. |
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Term
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Definition
| (overt data, objective data) Information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled. |
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Term
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Definition
| Data that are apparent only to the person affected; can be described or verified only by that person. |
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Term
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Definition
| (covert data) Information (data) apparent only to the person affected that can be described or verified only by that person. |
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Term
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Definition
| The determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data. |
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Term
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Definition
| Client signs and symptoms that must be present to validate a nursing diagnosis. |
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Term
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Definition
| With regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out. |
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Term
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Definition
| A statement or conclusion concerning the nature of some phenomenon. |
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Term
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Definition
| Title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association (NANDA) standardized taxonomy of terms. |
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Term
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Definition
| The causal relationship between a problem and its related or risk factors. |
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Term
| Health Promotion Diagnosis |
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Definition
| Any activity undertaken for the purpose of achieving a higher level of health and well-being. |
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Term
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Definition
| Areas of health care unique to nursing, separate and distinct from medical management. |
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Term
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Definition
| An ideal or fixed standard; an expected standard of behavior of group members. |
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Term
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Definition
| The nurse's clinical judgment about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable. |
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Term
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Definition
| The three essential components of nursing diagnostic statements including the terms describing the problem, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms. |
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Term
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Definition
| Words that have been added to some NANDA labels to give additional meaning to the diagnostic statement. |
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Term
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Definition
| Factors that cause a client to be vulnerable to developing a health problem. |
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Term
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Definition
| Clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. |
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Term
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Definition
| A generally accepted rule, model, pattern, or measure. |
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Term
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Definition
| A diagnosis that is associated with a cluster of other diagnoses. |
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Term
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Definition
| A classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles. |
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Term
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Definition
| (NANDA) Describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. |
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Term
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Definition
| (Critical Pathways)Multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes. |
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Term
| Collaborative Interventions |
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Definition
| Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians. |
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Term
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Definition
| A visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows. |
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Term
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Definition
| Multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes. |
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Term
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Definition
| Activities carried out on the orders or supervision of a licensed physician or other health care provider authorized to write orders for nurses. |
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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
| A written or computerized guide that organizes information about the client's care. |
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Term
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Definition
| A part of a care plan that describes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions. |
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Term
| Independent Interventions |
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Definition
| Activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills. |
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Term
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Definition
| An observable client state, behavior, or self-reported perception or evaluation; similar to desired outcomes in traditional language. |
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Term
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Definition
| A plan tailored to meet the unique needs of a specific client - needs that are not addressed by the standardized plan. |
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Term
| Informal Nursing Care Plan |
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Definition
| A strategy for action that exists in the nurse's mind. |
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Term
| Multidisciplinary Care Plan |
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Definition
| A standardized plan that outlines the care required for clients with common, predictable - usually medical - conditions. |
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Term
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Definition
| Any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes. |
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Term
| Nursing Interventions Classification (NIC) |
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Definition
| A taxonomy of nursing actions each of which includes a label, a definition, and a list of activities. |
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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
| Rules developed to govern the handling of frequently occurring situations. |
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Term
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Definition
| The process of establishing a preferential order for nursing strategies. |
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Term
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Definition
| Steps used in carrying out policies or activities. |
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Term
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Definition
| A predetermined and preprinted plan specifying the procedure to be followed in a particular situation. |
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Term
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Definition
| The scientific reason for selecting a specific action. |
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Term
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Definition
| Formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction) |
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Term
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Definition
| An order that may be carried out indefinitely until another order is written to cancel it, or that may be carried out for a specified number of days. |
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Term
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Definition
| Examination or review of records. |
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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
| Evaluation of a client's health care while the client is still receiving care from the agency. |
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Term
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Definition
| A planned ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes. |
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Term
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Definition
| A statement that consists of two parts: a conclusion and supporting data. |
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Term
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Definition
| The phase of nursing process in which the nursing care is plan is put into action. |
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Term
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Definition
| All verbal and nonverbal activities people use when communicating directly with one another. |
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Term
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Definition
| Focuses on demonstrable changes in the client's health status as a result of nursing care. |
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Term
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Definition
| A component of quality assurance that focuses on how care was given. |
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Term
| Quality-Assurance (QA) Program |
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Definition
| An ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients. |
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Term
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Definition
| An organizational commitment and approach used to continuously improve all processes in the organization with the goal of meeting and exceeding customer expectations and outcomes; also known as total quality management (TQM) and continuous quality improvement (CQI). |
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Term
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Definition
| Evaluation of a client's record after discharge from an agency. |
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Term
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Definition
| Process for identifying factors that bring about deviations in the practices that lead to an event. |
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Term
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Definition
| An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. |
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Term
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Definition
| Focuses on the setting in which care is given. |
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Term
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Definition
| "Hands-on" skills such as those required to manipulate equipment, administer injections, and move or reposition clients. |
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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
| 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 clients 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
| (chart) A formal, legal document that provides evidence of a client's care. |
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Term
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Definition
| An informal oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies to resolve a problem. |
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Term
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Definition
| The process of making an entry on a client record; charting, recording. |
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Term
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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
| Process in which information about patient/client/resident care is communicated in a consistent manner including an opportunity to ask and respond to questions. |
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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 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) |
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Definition
| 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
| Problem-Oriented Record (POR) |
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Definition
| (Problem-Oriented Medical Record) 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 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 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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Term
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Definition
| A variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame. |
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Term
| What is the legal record of care? |
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Definition
| The client's chart or medical record. |
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Term
| The client's chart/record is what? |
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Definition
| A confidential, permanent, and legal document that is admissible in court. |
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Term
| Are nurses responsible for ensuring confidentiality? |
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Definition
| Yes, Nurses are legally and ethically responsible for ensuring that confidentiality is maintained. |
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Term
| Who should access a client's record? |
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Definition
| Only those health health care providers who are involved directly in the client's care. |
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Term
| What should nursing care provided and recorded as documentation or charting reflect? |
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Definition
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Term
| Does computer charting make it easier or more difficult to maintain confidentiality? |
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Definition
| More difficult because the chart is more readily available. |
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Term
| What information should be included in the chart? |
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Definition
- Assessments
- Medication Administration
- Treatments given and the client's responses
- Client Education |
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Term
| Who mandates the use of computerized databases to expedite the accreditation process? |
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Definition
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Term
| What do health care facilities use computerized data for? |
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Definition
| Managing budgets, quality improvement programs, research, and many other endeavors. |
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Term
| What is the purpose for medical records? |
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Definition
| Communication, legal documentation, financial billing, education, research, and auditing/monitoring. |
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Term
| What is the purpose of reporting? |
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Definition
| TO provide continuity of care when several nurses provide care to the client. |
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Term
| How should reporting be conducted? |
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Definition
| In a confidential manner. |
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Term
| How should documentation appear? |
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Definition
- Factual
- Accurate and Concise
- Complete and Current
- Organized |
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Term
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Definition
| Subjective and objective data can be documented. |
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Term
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Definition
| Can be documented as direct quotes, within quotation marks, or summarized and identified as the client's statement. |
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Term
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Definition
| Should be descriptive and should include what the nurse see,s hears, feels, and smells. Document without derotgatory words, judgments, or opinions. Document the client's behavior accurately. |
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Term
| What is another more correct way of writing "the client is agitated"? |
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Definition
| " the client is pacing back and forth in his room, yelling loudly" |
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Term
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Definition
| Information that is documented must be precise. Facts should be documented without any interpretations of the situation. |
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Term
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Definition
| Information that is documented should be comprehensive and timely. Never pre-chart an assessment, intervention, or evaluation. |
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Term
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Definition
| Communicate information in a logical order. |
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Term
| How should you always begin an entry in a chart? |
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Definition
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Term
| What color ink should be used when charting? |
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Definition
| Black ink in legible writing. |
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Term
| How should you enter data that you might have forgotten? |
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Definition
| As a late entry. It must include the time the charting was done and the specific time the charting reflects. |
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Term
| How should all documentation end? |
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Definition
| With the signature and title of the person making the entry. |
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Term
| What is important to do when computer charting? |
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Definition
- Log out
- Keep Password a secret
- Make sure the screen isn't easily visible to others. |
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Term
| What are flow charts used for? |
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Definition
| To show trends in vital signs, blood glucose levels, pain level, and other frequently performed assessments. |
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Term
| What is narrative documentation used for? |
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Definition
| To record information as a sequence of events. |
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Term
| Charting by exception uses What for what reason? |
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Definition
- Standardized forms
- To identify normal findings/values and allows selective documentation of abnormal findings. |
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Term
| What do problem-oriented medical records consist of? |
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Definition
| A database, problem list, care plan, and progress notes. |
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Term
| What does SOAPIE stand for? |
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Definition
S - Subjective data
O - Objective data
A - Assessment (includes a nursing diagnosis based on the assessment)
P - Plan
I - Intervention
E - Evaluation |
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Term
|
Definition
P - Problem
I - Intervention
E - Evaluation |
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Term
| What does DAR (focus charting) stand for? |
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Definition
D - Data
A - Action
R - Response |
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Term
| What are the advantages of computerized documentation? |
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Definition
Standardization, accuracy, confidentiality, and easy access for multiple users.
Acquisition and transfer of client information is expedited. |
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Term
| What are the disadvantages of computerized documentation? |
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Definition
| Learning the computerized system, knowing how to correct errors, and maintaining security. |
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Term
| How can a change-of-shift report be obtained? |
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Definition
| Face-to-face, audiotaped, or presented during walking rounds in the client's room. |
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Term
| What should an effective change-of-shift report contain/look like? |
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Definition
- Include significant objective information about the client's health problems
- Given in a logical order
- Free of gossip and personal opinion
- Relates recent changes in medications, treatments, procedures, or the discharge plan. |
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Term
| What is important to do when making a telephone report? |
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Definition
- have all data prepared prior to contacting any member of the interdisciplinary team
- use a professional demeanor
- use exact, relevant, and accurate information
- document the name of the person called, the time, content of message, and the instructions or information received following the report. |
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Term
| When would a telephone order or verbal order be necessary? |
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Definition
| During an emergency or otherwise unusual time. |
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Term
| What are ways to prevent errors in verbal or telephone orders? |
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Definition
- have a second RN/LPN listening
- Repeat back the order given, making sure to include the medication name (spell if needed), dosage, time, and route.
- document reading back the order and the presence of second nurse
- question any order that may seem contraindicated due to previous order or to the client's condition. |
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Term
| What should transfer reports include? |
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Definition
- Client's demographic information
- Client's medical diagnosis & providers
- An overview of the client's health status, plan of care, & recent progress.
- alterations that may cause an emergency
- most recent vital signs
- current medications & last dose administered
- allergies
- diet & activity orders, advanced dirrectives & resuscitation status
- need for equipment
- family involvement & health care proxy |
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Term
| What should an incident report include? |
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Definition
- facts documented without judgement or opinion
- should not be referred to in the client's medical record |
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Term
| What do incident reports do? |
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Definition
| Improve health care quality by contributing to changes designed to make improvements. |
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Term
| What is the Privacy Rule? |
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Definition
| Introduced to promote the use of standard methods of maintaining the privacy of protected health information (PHI) among healthcare agencies. |
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Term
| The Privacy Rule includes what? |
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Definition
- Only direct care workers access pt. file
- Pt. has right to read/copy med. records
- No part of pt. chart can be copied or exchanged unless between authorized health care institutions
- Pt. record must be kept secure
- Electronic records should be password protected & protected from public view
- Pt. info. must not be disclosed to unauthorized individuals/family members.
- Communication about pt. should only take place in private. |
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Term
| What do the information security protocols include? |
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Definition
- Logging off the computer before leaving the workstation to ensure that others can't view PHI on the monitor
- Never share ID or password
- Never leave pt. chart or other PHI where others can access it.
- Shred any printed or written client info used for reporting or client care after it is no longer needed. |
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Term
| What are the steps of the nursing plan? |
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Definition
- Assessment/data collection
- Analysis/data collection
- Planning
- Implementation
- Evaluation |
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Term
| What does assessment/data collection involve? |
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Definition
| The systematic collection of information about the client's present health status to identify the client's needs and to identify additional data to collect based on the nurse's findings. |
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Term
| What are methods of data collection? |
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Definition
| - observation, interviews with client and family, medical history, comprehensive or focused physical exam., diagnostic & lab reports, & collaboration |
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Term
| How can a nurse effectively collect data? |
|
Definition
- Ask appropriate questions
- listen carefully to pt. responses
- conduct excellent head-to-toe physical |
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Term
| What does a nurse use critical thinking skills for? |
|
Definition
- identify the client's health status or problems
- interpret or monitor the collected database
- assess pt. health status and coping mechanisms
- provide direction for nursing care |
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Term
| What does analysis/data collection require a nurse to do with data? |
|
Definition
- recognize patterns or trends
- compare the data with expected standards or reference ranges
- arrive at conclusions to guide nursing care |
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Term
| What does the nurse do during the planning process? |
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Definition
| The nurse sets priorities, determines client outcomes, and selects specific nursing interventions. |
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Term
|
Definition
| Identify the optimal client status. |
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Term
| What does the client outcome do? |
|
Definition
| Identify the observable criterion that will determine success or failure of the goal. |
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Term
| What should the client outcome/goal be? |
|
Definition
- client-centered
- singular
- observable
- measurable
- time-limited
- mutually agreed upon
- reasonable |
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|
Term
| Who defines the scope of practice for a nurse? |
|
Definition
- ANA Standards of Practice
- State Nurse Practice Acts
- Health Care Facility Policies |
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