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10 Cards in this Set

  • Front
  • Back
Accurate written information in a medical record used for evaluation.
Documentation
The process involving examination of a condition and judgment as to whether change has occurred.
Evaluation
Thinking process used by the nurse during evaluation to make clinical decisions and redirect nursing care.
Critical Thinking
An expected response that indicates resolution of a nursing diagnosis or maintenance of a health state.
Goal
Elements of the nursing care plan to which the nurse compares actual client responses to determine if the goals of care have been met
Expected Outcome
Process employed by the nurse to collect Data
Assessment
What may need to be changed if evaluation reveals that expected outcomes are not met or are partially met
Nursing Diagnosis Priorities and Interventions
System for identifying, labeling, validating, and classifying nursing-sensitive client outcomes.
Nursing Outcomes Classification
The minimum level of care defined for types of therapies established to treat health problem.
Standard of Care
A program concerned with exceeding standards of care and examining ways to be more efficient, to improve services, and to increase client satisfaction.
Quality Improvement