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27 Cards in this Set
- Front
- Back
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Discussion |
Informal oral consideration of a subject by two or more healthcare personnel |
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Oral written or computer based communication intended to convey information to others |
Report |
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Oral written or computer based communication intended to convey information to others |
Report |
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Also called chart or client record form a legal document that provides evidence of a client's care can be written or computer based |
Record |
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Prevents fragmentation repetition and delays in care |
Communication |
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Nurses use baseline and ongoing data to evaluate effectiveness of the care plan |
Planning client care |
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Review client records for quality assurance purposes |
Auditing health agencies |
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Treatment plans for a number of clients with the same health problems can get information helpful in treating other clients |
Research |
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From the federal government must contain drg's |
Reimbursement |
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Admissible in court as evidence unless client objects because information client gives to primary care provider is confidential |
Legal documentation |
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Identify agency needs such as over utilized and underutilized hospitals services |
Healthcare analysis |
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Grouped information into three categories problems interventions evaluation on going to assessment flowsheet and progress notes |
PIE |
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Focus on plan concerns and strength progressed most organized in DAR format |
Focus charting |
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Assessment phase |
Data |
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Planning and implementing phase |
Action |
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Evaluation phase |
Response |
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Developed to manage volume of information |
Computerized documentation |
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Quality cost effective care delivered within the established length of stay uses multidisciplinary approaches critical pathways |
Case management model |
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A goal that is not met |
Variance |
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Describe the client's ongoing status in record |
Documenting the nursing process |
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Comprehensive admission assessment incline press admitted to nursing unit |
Admission nursing assessment |
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Joint commission requires physical report to include evidence of planned assessment nursing diagnosis nursing interventions and outcomes current nursing care plans |
Nursing care plan |
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Concise method of organizing and recording data series of cards cat in a portable index follow around a computer-generated form |
Kardexes |
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Body temperature pulse respiratory rate blood pressure rate other significant clinical data |
Graphic record |
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Provide information about progress client is working toward achieving desired outcomes |
Progress notes |
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Completed when climb just charged terms that can be readily understood |
Nursing discharge or referral summaries |
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Based on professional standards by the role and state regulations policies of health care agency |
Long-term care documentation |
