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172 Cards in this Set
- Front
- Back
Chapter 6
Case Management |
A method for delivering nursing care in which the nurse is responsible for a caseload of clients across the healthcare continuum.
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Coinsurance
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An insurance plan in which the client pays a percentage of the payment and some other group (e.g., employer, government) pays the remaining percentage.
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Critical Pathways
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multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes.
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Diagnosis-related Groups (DRGs)
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A Medicare payments system to hospitals and physicians that established fees according to diagnosis.
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Differentiated Practice
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A system in which the best possible use of nursing personnel is based on their educational preparation and resultant skill sets.
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Healthcare Systems
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The totality of services offered by all health disciplines.
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Health Maintenance Organization (HMO)
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A group health care agency that provides basic and supplemental health maintenance and treatment services to voluntary enrollees.
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Independent Practice Associations (IPAs)
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Provide care in offices; clients pay a fixed prospective payment and IPA pays the provider; earnings or losses are assumed by the IPA.
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Integrated Delivery System (IDS)
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A system that incorporates acute care services, home health care, extended and skilled care facilities and outpatient services.
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Licensed Vocational (practical) Nurse (LVN/LPN)
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A nurse who practices under the supervision of a registered nurse, providing basic direct technical care to clients.
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Managed Care
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a method of organizing care delivery that emphasized communication and coordination of care among all health care team members.
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Medicaid
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A U.S. federal public assistance program paid out of general taxes and administered through the individual states to provide health care for those who require financial assistance.
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Medicare
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A national and state health insurance program fro U.S. residents older than 65 years of age.
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Patient-focused Care
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Delivery model that brings all services and care providers to the client.
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Preferred Provider Arrangements (PPAs)
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Similare to PPOs, but PPAs can contract with individual health care providers; the plan can be limited or unlimited.
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Preferred Provider Organization (PPOs)
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A group of physicians of a hospital that provides companies with health services at a discounted rate.
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Supplemental Security Income (SSI)
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Special payments for people with disabilities, those who are blind, and people who are not eligible for Social Security; these payments are not restricted to health care costs.
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Team Nursing
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The delivery of individualized nursing care to clients by a team lead by a professional nurse.
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Chapter 4
Advance Health Care Directives |
A variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences.
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Answer (legal)
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A written response made by the defendant.
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Assault
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An attempt or threat to touch another person unjustifiably.
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Autopsy
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An examination of the body after death to determine the cause of death and to learn more about a disease process.
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Battery (legal)
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The willful or negligent touching of a person (or the person's clothes or even something the person is carrying), which may or may not cause harm.
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Breach of Duty
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A standard of care that is expected in the specific situation but that the nurse did not observe; this is the failute to act as a reasonable, prudent nurse under the circumstances.
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Burden of Proof
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The duty of proving an assertion (claim).
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Causation
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A fact that must be proven that the harm occurred as a direct result of the nurse's failure to follow the standard of care and the nurse could have (or should have ) known that failure to follow the standard of care could result in such harm.
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Civil Action
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Deals with the relationship between individuals in society.
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Civil Law
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The body of law that deals with relationships among private individuals; also know as private law.
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Common Law
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The body of principles that evolves from court decisions.
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Complaint (legal)
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A document filed by a plaintiff.
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Contract
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A written or verbal agreement between two or more people to do or not to do some lawful act.
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Contract Law
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The enforcement of agreements among private individuals or the payment of compensation for failure to fulfill the agreement.
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Contractual Obligations
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Duty of care extablished by the presence of an expressed or implied contract.
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Contractual Relationships
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Vary among practive settings; may be as an indepentent or employer-employee relationship.
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Coroner
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A physician who is authorized by the county or other government agency to determine causes of death under unusual circumstances.
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Credentialing
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The process of determining and maintaining competence in practice; includes licensure, registration, certification, and accreditation.
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Crime
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An act committed in violation of public (criminal) law and punishable by a fine and/or imprisonment.
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Criminal Actions
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Deal with disputes between an individual and the society as a whole.
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Criminal Law
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Deals with actions against the safety and welfare of the public.
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Damages
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If malpractice caused the injury, the nurse is held liable for damages that may be compensated.
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Decision (legal)
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Outcome made by a judge
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Defamation (legal)
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A commjnication that is false, or made with careless disregard for the truth, and results in injury to the reputation of another.
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Defendants (legal)
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Person against whom a plaintiff files a complaint.
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Delegation
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Transference of responsibility and authority for an activity to a competent individual.
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Discovery (legal)
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Pretrial activites to gain all of the facts of a situation.
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Do Not Resuscitate (DNR)
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"No code", expressed wish for no resuscitation in the event of a respiratory or cardiac arrest.
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Duty
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The nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care.
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Euthanasia
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The act of painlessly putting to death persons suffering from incurable or distressing disease.
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Expert Witness
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One who has special training, experience, or skill in a relevant area and is allowed by the court of offer an opinion on some issue within that area of expertise.
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Express Consent
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An oral or written agreement.
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False Imprisonment
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The unlawful restraint or detention of another person against his or her wishes.
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Felony
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A crime of a serious nature, such as murder, punishable by a term in prison.
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Foreseeability
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A link that must exist between the nurse's act and the injury suffered.
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Gross Negligence
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Involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm.
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Harm (injury)
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The client or plaintiff must demonstate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client; the plaintiff will be asked to document physical injury, medical costs, loss of wages, "pain and suffering", and any other damages.
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Health Care Proxy
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A legal statement that appoints a proxy (a person authorized to act for another) to make medical decisions for the client in the event the client is unable to do so.
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Impaired Nurse
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A nurse whose practice has deteriorated because of chemical abuse.
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Implied Consent
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Consent that is assumed in an emergency when consent cannot be obtained from the client or a relative.
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Implied Contract
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A contract that has not been explicitly agreed to by the parties but that the law nevertheless considers to exist.
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Informed Consent
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A client's agreement to accept a course of treatment or a procedure after receiving complete information, including the risks of treatment and facts relating to it, from the health care provider.
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Injury
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(Harm) The client or plaintiff must demonstate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client; the plaintiff will be asked to document physical injury, medical costs, loss of wages, "pain and suffering", and any other damages.
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Inquest
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A legal inquiry into the cause or manner of a death.
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Interstate Compact
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An agreement between two or more states.
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Invasion of Privacy
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A direct wrong of a personal nature, it injures the feeling of the person and does not take into account the effect of revealed information on the standing of the person in the community.
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Law
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A rule made by humans that regulates social conduct in a formally prescribed and binding manner.
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Liability
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The quality or state of being legally responsible for one's obligation and action and to make financial restitution for wrongful acts.
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Libel
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Defamation by means of print, writing, or pictures.
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License
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A legal permit granted to individuals to engage in the practice of a profession and to use a particular title.
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Litigation
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The action of a lawsuit.
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Living Will
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A document that states medical treatment (s) the client chooses to omit or refuse in the event that the client is unable to make these decisions.
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Malpractice
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The negligent acts of persons engaged in professions or occupation in which highly technical or professional skills are employed.
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Mandated Reporters
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A role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities.
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Manslaughter
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Second-degree murder.
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Medical Examiner
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A physician who usually has advanced education in pathology or forensic medicine who determines causes of death.
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Misdemeanor
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A legal offense usually punishable by a fine or a short-term jail sentence, or both.
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Mutual Recognition Model
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A regulatory model developed by the National Council of State Boards of Nursing (NCSBN), which allows for multistate licensure.
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Negligence
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Failure to behave in a reasonable and prudent manner; an unintentional tort (wrongful act).
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Plaintiff
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A person claiming infringement of legal rights by one or more persons.
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Postmortem Examination
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(Autopsy) An examination of the body after death to determine the cause of death and to learn more about a disease process.
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Private (civil) Law
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The body of law that deals with relationships between private individuals.
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Public law
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Refers to the body of law that deals with relationships between individuals and the government and governmental agencies.
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Res Ipsa Loguitur "The thing that speaks for itself"
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A legal doctrine that relates to negligence in which the harm cannot be traced to a specific health care provider or standard but does not normally occur unless there has been a negligent act.
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Respondeat Superior
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A legal term meaning "let the master answer"; the employer assumes responsibilty for the conduct of the employee and can also be held responsible for malpractice by the employee.
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Responsibility
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The specific accountability or liability associated with the performance of duties of a particular role.
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Right (legal)
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A privilege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily.
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Slander
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Defamation by the spoken word, stating unpriviliged (not legally protected) or false words by which a reputation is damaged.
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Standards of Care
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The skills and learning commonly possessed by members of a profession.
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Statutory Laws
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Laws enacted by any legislative body.
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Strike
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An organized work stoppage by a group of employees to express a grievance, enforce a demand for changes in condition of employment, or solve a dispute with management.
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Tort
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A civil wrong committed against a person or a person's property.
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Tort Law
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Law that defines and enforces duties and rights among private individuals that are not based on contractual agreements.
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Trial
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The period during which all relevant facts are presented to a jury or judge.
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Unprofessional conduct
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One of the grounds for action against the nurse's license; includes incompetence or gross negligenc, conviction of practicing without a license, falsification of clients records, and illegally obtaining, using, or possessing controlled subtances.
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Verdict
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The outcome made by a jury.
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Chapter 5
Accountablility |
The ability and willingness to assume responsibility for one's actions and to accept the consequences of one's behavior.
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Active Euthanasia
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Actions that directly bring about the client's death with or without consent.
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Advocate
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Individual who pleads the cause of another or argues or pleads for a cause or proposal.
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Assisted Suicide
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A form of active euthanasia in which clients are given the means to kill themselves.
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Attitudes
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Mental stance that is composed of many differnt beliefs; usually involving a positive or negative judgment toward a person, object, or idea.
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Autonomy
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The state of being independent and self-directed, without outside control, to make one's own decisions.
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Beliefs
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Interpretations or conclusions that one accepts as true.
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Beneficence
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The moral obligation to do good or to implement actions that benefit clients and their support persons.
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Bioethics
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Ethical rules or principles that govern right conduct concerning life.
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Code of Ethics
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A fomal statement of a group's ideals and values; a set of ethical principles shared by members of a group, reflecting their moral judgments and serving as a standard for professional actions.
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Consequence-based (teleological) Theories
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The ethics of judging whether an action is moral.
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Ethics
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The rules or principles that govern right conduct.
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Fidelity
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A moral principle that obligates the individual to be faithful to agreements and responsibilities one has undertaken.
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Justice
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Fairness
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Moral Development
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Process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done.
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Moral Distress
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The psychological disequilibrium that occurs when a person believes he or she knows the right course of action to take, but cannot carry out that action because of some obstacle, such as institutional constraints or lack of power.
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Moral Rules
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Specific prescriptions for actions.
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Morality
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A doctrine or system denoting what is right and wrong in conduct, character, or attitude.
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Nonmaleficence
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The duty to do no harm.
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Nursing Ethics
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Ethical issues that occur in nursing practice.
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Passive Euthanasia
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Allowing a person to die by withholding or withdrawing measures to maintain life.
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Personal Values
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Values internalized from the society or culture in which one lives.
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Principles-based (deontological) Theories
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Emphasize individual rights, duties, and obligations.
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Professional Values
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Values acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers.
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Relationships-based (caring) Theories
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Stress courage, generosity, commitment, and the need to nurture and maintain relationships.
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Responsibility
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The specific accountability or liability associated with the performance of duties of a particular role.
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Utilitarianism
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A specific, consequence-based, ethical theory that judges as right the action that does the most good and least amount of harm for the greatest number of persons; often used in making decisions about the funding and delivery of health care.
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Utility
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see Utilitarianism
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Value System
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The organization of a person's values along a continuum of relative importance.
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Values
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Something of worth; a belief held dearly by a person.
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Values Clarification
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A process by which individuals define their own value.
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Veracity
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A moral pinciple that holds that one should tell the truth and not lie.
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Chapter 9
Clinical Decision Support Systems |
Electronic forms of charts, templates, algorithms, and other tools to assist in reaching decisions regarding client care, which incorporate evidence from the literature into particular client situations in order to guide care planning.
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Computer-based Patient Records (CPRs)
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Electronic client data retrievable by caregivers, administrators, accreditors, and other persons who require the data.
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Data Warehousing
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The accumulation of large amounts of data that are stored over time.
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Distance Learning
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Learning in which people communicate effectively across long distances.
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Electronic Medical Records (EMRs)
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Electronic client data retrievable by caregivers, administrators, accreditors, and other persons who require the data.
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Hospital Information System (HIS)
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Computer software program suite used to manage client, financial, and administrative data.
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Management Information System (MIS)
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Software designed to facilitate the organization and application of data used to manage an organization or department.
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Nurse Informaticist
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An expert who combines computer, information, and nursing science to develop policies and procedures that promote effective use of computerized records by nurses and other health care professionals.
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Nursing Informatics
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The science of using computer information systems to the practice of nursing.
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Technology
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The use of computers to systematically solve problems.
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Telemedicine
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Technology used to transmit electronic medical data about clients to persons at distant locations.
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Chapter 15
Change-of-shift report |
A report given to nurses on the next shift.
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Chart
(Client record) |
A formal, legal document that provides evidence of a client's care.
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Charting
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The process of making an entry on a client record.
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Charting by exception (CBE)
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A documentation system in which only significant findings or exceptions to norms are recorded.
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Client record
(Chart) |
A formal, legal document that provides evidence of a client's care.
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Discussion
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An informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
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Documenting
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The process of making an entry on a client record; charting, recording.
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Flow Sheet
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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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Focus charting
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A method of charting that uses key words or foci to describe what is happening to the client.
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Handoff communication
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A process in which information and patient/client/resident care is communicated in a consistent manner including an opportunity to ask and respond to questions.
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Kardex
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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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Narrative charting
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A descriptive record of client data and nursing interventions, written in sentences and paragraphs.
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PIE
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An acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions.
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Problem-oriented medical record (POMR)
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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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Problem-oriented record (POR)
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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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Progress note
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Chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes.
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Record
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A written communication providing formal, legal documentation of a client's progress.
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Recording
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The process of making written entries about a client on the medical record.
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Report
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Whether oral or written, it sould be concise, including pertinent information but no extraneous detail.
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SOAP
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An acronym for a charting method tht follows a recording sequence of subjective date, objective data, assessment, and planning.
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Source-oriented record
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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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Variance
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A variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame.
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Chapter 32
Asphyxiation |
Lake of oxygen due to interrupted breathing.
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Bioterrorism
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Intentional attack using biological weapons such as viruses, bactera, or other germs.
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Burn
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Results from excessive exposure to thermal, chemical, electric, or radioactive agents.
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Carbon monoxide
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An odorless, colorless, tasteless gas that is toxic.
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Chemical restraints
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Medications used to control socially disruptive behavior.
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Electric shock
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Occurs when a current travels through the body to the ground rather than through electic wiring, or from static electicity that builds up on the body.
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Heimlich maneuver
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Abdominal thrusts used to clear an obstructed airway.
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Physical restraints
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Any manual method or physical or mechanical device, material, or equipment attached to the client's body that cannot be removed easily and that restricts the client's movement.
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Restraints
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Protective devices used to limit physical activity of the client or a part of the body.
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Safety monitoring devices
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An electronic sensor or monitor that detects when clients are attempting to get out of a bed or chair and triggers an alarm.
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Scald
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A burn from a hot liquid or vapor, such as steam.
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Seizure
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A sudden onset of excessive electrical discharges in one or more areas of the brain.
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Seizure precautions
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Safety measures taken to protect clients from injury should they have a seisure.
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