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Definition
| process whereby a professional association or nongovernmental agency grants to a school or institution for demonstrated ability to meet predetermined criteria |
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Term
| Diagnosis-related Group (DRG) |
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Definition
| group of clients established for health care reimbursement based on length of stay |
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Definition
| anything written or printed you rely on as record or proof for authorized persons |
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Definition
| another form of discussion whereby one professional caregiver gives formal advice about the care of a client to another caregiver. Ex: nurse consulting with a specialist. |
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Term
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Definition
| oral, written, or audiotaped exchanges of information between caregivers. Oral usuallly has a lot of patients. |
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Term
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Definition
| confidential, permanent legal document of information relevant to a client's health care |
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Definition
| an arrangement for services by another care provider |
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Term
| Problem-oriented medical record |
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Definition
| method of documentation that emphasizes the client's problems |
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Term
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Definition
| s-subjective data, o-objective data, a-assessment(diagnosis based on data), p-plan (what the caregiver plans to do) |
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Definition
| i-intervention, e-evaluation |
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Term
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Definition
| p-problem, i-intervention, e-evaluation |
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Term
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Definition
| problem-oriented medical record |
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Term
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Definition
| progress notes that focus on a single patient problem |
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Term
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Definition
| narrative format including DAR notes, incorporates all aspects of the nursing process; looks away from negative connotation |
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Term
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Definition
| d-data(subjective & objective), a-action or nursing intervention, r- response of the client; gives critical thinking |
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Term
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Definition
| client's chart has a separate section for each discipline (nursing, medicine, social work, respiratory therapy) to record data |
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Term
Charting by Exception
(CBE) |
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Definition
| focuses on documenting deviations from the established nor or abnormal findings |
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Term
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Definition
| model of care; usually a nurse or social worker coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care for patient |
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Term
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Definition
| multidisciplinary care plans that include client problesms, key interventions, and expected outcomes within an established time frame |
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Term
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Definition
| interventions or outcomes that are not achieved as anticipated |
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Term
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Definition
| forms that allow nurses to quickly and easily enter assessment data about the client, including vital signs and routine repetitive care, such as hygiene measures, ambulation, meals, weights, and safety and restraint checks |
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Term
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Definition
| a portable "flip over" file or notebook is a quick reference to the particular need of the client |
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Term
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Definition
| entries describing patient care over a 24 hr period; translated into an acuity score and measured compared to other patients by severity of illness |
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Term
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Definition
| preprinted, established guidelines that are used to care for clients who have similar health problems |
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Term
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Definition
| given orally by nurses in person, by audiotape recordings, or during walking-planning rounds at each client's bedside |
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Term
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Definition
| verbal information by phone or in person when a patient moves from one place to another healthcare; to keep consistent level of care |
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Term
| Incident/Occurent Reports |
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Definition
| confidential document that describes any patient accident while the patient is on the health care premises |
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Term
Information technology
(IT) |
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Definition
| mangement and processing of information, generally with the assistance of computers |
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Term
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Definition
| defined by the ANA as a specialty that integrates nursing science, computer science, and infromation science to manage and communicate data, information, and knowledge in nursing practice |
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Term
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Definition
| collection of alphanumeric characters that a user types into the computer before accessing a program |
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Term
CPOE-
computerized physician order entry |
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Definition
| process where the physician or an advanced practice nurse directly enters orders for client care into the hospital information system |
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Term
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Definition
| rather than clients bc they will most likely live the rest of their life there |
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