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57 Cards in this Set
- Front
- Back
Assignment
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A downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another
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Collaborative Care Plan
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Critical Pathway: Multidisciplanary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
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Collaborative Interventions
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actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers dietitians and physicians.
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Dependent Interventions
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those activities carried out on the order of the physician, under the phusician's supervision, or according to specified routines
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Discharge Planning
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the process of anticipating and planning for client needs after discharge.
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Formal Nursing Care Plan
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a written or computerized guide that organizes information about the client's care.
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Goal/Desired Outcomes
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a part of a care plan that describes in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions.
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Independent Interventions
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activities that the nures is licensed to initiate as a result of the nurse's own knowledge and skills.
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Indicator
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an observable patient state, behavior, or self-reported perception or evaluation similar to desired outcomes in traditioal language
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Individualized Care Plan
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a plan tailored to meet the unique needds of a specific client--needs that are not addressed by the standardized care plan
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Informal Plan
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a strategy for action that exists in the nurse's mind
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Multidisciplainary Care Plan
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a standardized plan that outlines the care required for clients with common, predictable--usually medical--conditions
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Nursing Interventions
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any treatments, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes
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Nursing Interventions Classification (NIC)
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a taxonomy of nursing interventions developed by Iowa Intervention Project
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Nursing Orders
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instructions written on the care plan to direct the specific nursing activities that help the client achieve desired outcomes/goals.
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Nursing Outcomes Classification (NOC)
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a taxonomy for describing client outcomes that respond to nursing interventions
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Policies
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rules developed to govern the handling of frequently occurring situations.
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Priority Setting
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the process of establishing a preferential order for nursing strategies.
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Procedures
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steps used in carrying out policies or activities
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Protocols
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a predetermined and preprinted plan specifying the procedure to be followed in a particular situation
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Rationale
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the scientific reason for selecting a specific action.
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Standardized Care Plan
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preprinted guides for giving nursing care to clients with common needs (e.g. nursing diagnosis)
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Standing Order
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a written document about policies, rules, regulation, or orders regarding client care; give nurses the authority to carry out specific actions under certain curcumstances.
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Activities
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the specific nursing actions needed to carry out the interventions (or nursing orders)
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Cognitive Skills
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(intellectual skills) that include problem solving, decision making, critical thinking, and creativity.
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Evaluating
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a planned ongoing, purposeful activity in which clients and health care professionals monitor progress.
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Evaluation Statement
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a statement that consists of two parts: a conclusion and supporting data.
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Implementing
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the phase of the nursing process in which the nursing care plan is put into action
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Interpersonal Skills
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all the verbal and nonverbal activities people use when communicating directly with one another
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Outcome Evaluation
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focuses on demonstratable changes in the client's health status as result of nursing care
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Process Evaluation
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a component of quality assurance that focuses on how care was given
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Quality Improvement
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an organizational commitment and approach used to continuously improve all processes in the organization with the goal of meeting and exceeding customer expectations and outcomes; also known as total quality management (TQM) and continuous quality improvement (CQI)
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Quality-Assurance Program
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an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients
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Structure Evaluation
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focuses on the setting which care is given
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Technical Skills
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hands-on skills such as those required to manipulate equipment, administer injections, or move or reposition patients
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Change -of-Shift Report
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a report given to nurses on the next shift
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Chart
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a formal, legal document that provides evidence of a client's care (Client Record)
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Charting
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the process of making an entry on a client record (Charting or Recording)
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Charting by Exception (CBE)
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a documentation system in which only significant findings or exceptions to the norm are recorded
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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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Flowsheet
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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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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 recored and arranged according to the client's problems, rather than according to the source of the information (also Problem-Oriented Record (POR))
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Progress Notes
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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 ofmaking written entries about a client on the medical record
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Report
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whether oral or written, it should be concise, including pertinent information but no extraneous detail
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SOAP
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an acronym for a charting method that follows a recording sequence of Subjective data, Objective data, Assessment and Planning.
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Source-Orientend 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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Standards of Care
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the skills and learning commonly possessed by members of a profession
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Delegation
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the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome.
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Confidentiality
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any information a subject relates will not be made public or available to others without the subject's consent
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Computer-Based Client Record
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electronic client data retrievable by caregivers and other personnel who reqiure data.
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Case Management Model
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a method for delivering nursing care in which the nurse is responsible for a caseload of clients across the health continuum.
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