Fundamentals Of Nursing Ch. 6

Front 1

Auditors

Back 1

People appointed to examine patients charts

Front 2

Chart

Back 2

Health care record, a legal recording that is used to meet the demands of the patients needs, accredidation, medical insurance and legal systems

Front 3

Charting

Back 3

Process of adding written information to a chart
also known as Charting, Recording, Documenting

Front 4

Charting By Exception
CBE

Back 4

CBE Complete Physical assesments, vital signs, IV site and other data that is recorded at the beginning of each shift

Front 5

Peer Review

Back 5

an appraisal by professional coworkers of equal status, appraises manner in which individual nurse conducts practice, education, manner and research

Front 6

Quality Asssurance assesment

Back 6

Audit in Healthcare evaluation that assesses the services provided as well as the results achieved

Front 7

DRG
Diagnosis Related Groups

Back 7

Classifies patients by age, diagnosis, and surgical procedures

Front 8

Nursing Notes

Back 8

Form on patients chart where nurse records observations, care given and patients response

Front 9

5 Basic Purposes For Written Patient Records

Back 9

1. Written Communication
2.Permanent record for accountability
3.Legal Record of care
4.Teaching
5.Research and data collection

Front 10

Documentation is part of the

Back 10

Implementation phase of nursing process

Front 11

Always remember to incluse the

Back 11

Action and Time

Front 12

Audits

Back 12

"Review" of a specific chart for completion and appropriateness

Front 13

Peer Reviews

Back 13

are an appraisal by a prfessional "co-worker" of equal status

Front 14

Types of Charts

Back 14

Traditional Block
Narrative
Problem Orientated Medical record "POMR"
Problem list
Chating By Exception

Front 15

Traditional Block Chart

Back 15

Specific sections of info divided into blocks

Front 16

Narrative

Back 16

Records patient care in a descriptive manner

Front 17

POMR
Problem Orientated Medical Record

Back 17

A. Based on a scientific method of solving problems
B.Data based, accumulated data and info

Front 18

Problem List

Back 18

a. active or inactive problem,
b. divided into seperate disciplines

Front 19

Charting By Exceptions

Back 19

A. Charting only what is abnormal
B.Charting changes in condition or new concerns of patient

Front 20

RN is

Back 20

Responsible for assesments admission history and development of careplan

Front 21

DRG
Diagnosis Related Group

Back 21

A system that classifies patient by age, diagnosis and surgical procedure, used to predict length of time in hospital or use of hospital resources. Established by insurance companies

Front 22

Critical Pathways
"an integrated plan of care"

Established Guidelines, Protocal for Length of stay and diagnosis

Back 22

Established to provide quality, consistent care in a cost effevtive manner, Usually determined by the length of stay for the diagnosis

Front 23

SOAPIER
Problem solving with 7 different aspects in charting
"Soap Notes"

Back 23

Acronym for
Subjective
Objectyive
Assesment
Plan
Implementation
Evaluation
Revision

Front 24

Subjective

Patient giving info:

Back 24

Patient relays information , what they state or feel.
Only patient can provide subjective info.

Front 25

Objective
Nurse Observation

Back 25

Information that nurse can measuer factually and can describe as a fact

Front 26

Assessment
ie; Vital signs

Back 26

Analysis or potential diagnosis or cause of patients problem

Front 27

Plan
What Nurse is planning to do

Back 27

General statement of plan, what she will do on paper

Front 28

Implementation

Back 28

Specific care or action recorded on paper of what is done

Front 29

Evaluation

Back 29

Evaluates on paper whether or not the plan of care was effective

Front 30

Revision

Back 30

Written info regarding changes that should be made

Front 31

APIE

Back 31

Specific to problem areas
Plan/Problem
Implementation
Evaluation

Front 32

Plan/Problem

Back 32

General statement of care plan to be given

Front 33

Implementation

Back 33

Specific care given or action taken

Front 34

Evaluation

Back 34

The appraisal of the response or effectiveness of plan

Front 35

Kardex

Back 35

Consolidated card/index of patient orders in a centralized place

Front 36

Care plan

Back 36

care plan is preprinted guidelines for patients with similiar health problems that is later modified by RN for individual needs

Front 37

Incident report

Back 37

Documentation of any event that is not consistent with routine Hospital Procedures or patient care guidelines

Front 38

Discharge summary

Back 38

Important info for patient regarding the care that is needed after discharge