Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
17 Cards in this Set
- Front
- Back
|
Documentation |
Written legal record of all Pertinent interventions with the patient assessments diagnosis plans interventions and evaluations no I’m doing my homework |
|
|
Personal health record (PHR) |
Information sheets that contain the individuals medical history including diagnosis symptoms and medications |
|
|
Patient record |
A compilation of a patients health information; the patient record is the only permanent legal document that details the nurses interactions with the patient |
|
|
Electronica health record (EHR) |
Digital version of a patient’s chart that may contain the patient’s medical history diagnosis medications treatment plans immunization dates ,allergies ,radiology images ,and laboratory and test results |
|
|
Electronic medication administration records (eMAR or MAR) |
A patient’s medication record must include documentation of all medications administered to the patient (drug ,route ,time ,the nurse administering the drug ,the reason of administration, it’s effectiveness especially a narcotic ) some eMARs allow providers to look up detailed information about a medication |
|
|
Health information exchange (HIE) |
And electronics system that allows physicians nurses and pharmacists other healthcare providers and patients to appropriately access and securely share a patient’s vital medical information |
|
|
SOAP format |
Method of charting narrative progress notes; organizes data according to subjective information (S) objective information (O) assessment (A) and plan (P) |
|
|
A process for affective handoff communication among healthcare professionals about a patient’s condition standing for identity introduction situation background assessment recommendation and read back |
A process for affective handoff communication among healthcare professionals about a patient’s condition , standing for identity /introduction ,situation ,background assessment ,recommendation and read back |
|
|
Read-back |
A process in which a nurse or other healthcare provider repeated verbal order back to a position to ensure that it was correctly heard and interpreted |
|
|
Narrative notes |
Progress notes written by nurses any source oriented record |
|
|
Progress notes |
Any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes |
|
|
Bedside report |
Standardized, Streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family |
|
|
Purposeful rounding |
Proactive , systematic, nurse- driven, evidence based intervention that helps nurses anticipate and address patient needs. |
|
|
Handoff |
A nurses report to another nurse or health care provider about a patients status and progress |
|
|
Referral |
Process of sending or guiding someone to another source for assistance |
|
|
Incident report |
A report of any event that is not consistent with the routine operation of the healthcare facility and results in or has the potential to result in harm to a patient, employee, or visitor |
|
|
Discharge |
Description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals. |
