Documentation And Reporting

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Documentation

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Written legal record of all Pertinent interventions with the patient assessments diagnosis plans interventions and evaluations no I’m doing my homework

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Personal health record (PHR)

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Information sheets that contain the individuals medical history including diagnosis symptoms and medications

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Patient record

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A compilation of a patients health information; the patient record is the only permanent legal document that details the nurses interactions with the patient

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Electronica health record (EHR)

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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

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Electronic medication administration records (eMAR or MAR)

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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

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Health information exchange (HIE)

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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

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SOAP format

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Method of charting narrative progress notes; organizes data according to subjective information (S) objective information (O) assessment (A) and plan (P)

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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

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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

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Read-back

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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

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Narrative notes

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Progress notes written by nurses any source oriented record

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Progress notes

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Any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes

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Bedside report

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Standardized, Streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family

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Purposeful rounding

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Proactive , systematic, nurse- driven, evidence based intervention that helps nurses anticipate and address patient needs.

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Handoff

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A nurses report to another nurse or health care provider about a patients status and progress

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Referral

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Process of sending or guiding someone to another source for assistance

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Incident report

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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

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Discharge

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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.