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by gringo


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communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped
change-of-shift report

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
charting by exception

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
collaborative pathway / critical pathway
computer-generated patient data collection system that can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily, or compare the progress of groups of patients with similar diagnoses
computer-based record / electronic medical record (EMR)
to consult with someone to exchange ideas or to seek information, advice or instructions
confer

process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution
consultation
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
discharge summary

written, legal record of all pertinent interventions with the patient—assessments, diagnoses, plans, interventions, and evaluations
documentation
graphic record of abbreviated aspects of patient's condition (eg, vital signs, routine aspects of care)
flow sheet
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
focus charting
form used to record specific patient variables
graphic sheet
documentation that describes any injury or potential for injury suffered by a patient in a healthcare agency
incident report

trade name for a care plan documentation system that encompasses (1) prescriptions for nursing care related to activities of daily living; (2) nursing diagnoses and related patient goals and nursing orders; and (3) the nursing care related to diagnostic measures and the medical regimen
Kardex care plan

record documenting all medications administered to the patient, the nurse administering the drugs, and sometimes the reason the drug was administered and its effectiveness
medication record

a standard established by healthcare institutions that specifies the information that must be collected from every patient
minimum data set
descriptive record of the patient's condition; includes patient's response to interventions by health professionals and patient's progress toward goal achievement
narrative notes
formal meeting of nurses to discuss some aspect of patient's care
nursing care conference
procedure in which a group of nurses visit patients individually at bedside to gather information that helps to plan and to evaluate nursing care
nursing care round
a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)
OASIS (Outcome and Assessment Information Set)
a compillation of a patient's health information
patient record
internet based records that contain the individual's medical history, including diagnoses, symptoms and medications.
Personal Health Record (PHR)

documentation system that does not develop a separate 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
PIE charting
documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes
problem-oriented medical record (POR)
any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
progress notes
process of sending or guiding someone to another source for assistance
referral
oral, written, or computer-based communication of patient data with the purpose of informing others
reporting

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)
SOAP format

documentation system in which each healthcare group records data on its own separate form
source-oriented record
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
variance charting
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