CHAPTER 10 Flashcards
Audit
Review of records
Charting by exception (CBE)
system for documenting exceptions to normal illness or disease progression, using a shorthand method of charting what’s usual and normal
(Ex a physician claimed she did not record a patient’s temperature because she “charted by exception” and the temperature “must have been normal because she did not write anything”)
Computer-based patient record (CPR)
Record of patient’s health saved on and easily accessed by computer system
Computerized physician (provider) order entry (CPOE)
Allows authorized providers to enter all orders directly into the computer, electronically communicating orders to the labortaory, pharmacy, and nursing personnel.
Electronic medication administration record (eMAR)
Interfaces medication orders with pharmacy dispensing and allows direct computer charting of medication administration.
Clinical pathways
Models for ensuring quality care, providing direction about major interventions to perform for a specific condition.
Flow sheets
Form for charting routine nuring assesmentents or procedures often in a chart or table format/
FOCUS DAR
Documentation system that organizes data entry around data (D), action (A), and response (R). The FOCUS can be a problem area but does not need to be. An entry an be positive growth Or learning.
Handoff
Transfer of care for a patient from on health provider ot another.
Never events
serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers; and not reimbursed by medicare and medicaid
Examples of “never events” include surgery on the wrong body part; foreign body left in a patient after surgery; mismatched blood transfusion; major medication error; severe “pressure ulcer” acquired in the hospital; and preventable post-operative deaths.
Outcome and Assesment Information Set (OASIS)
A system that accurately measures the patient’s status at various specified points during an episode of care, thus providing the basis for measuring patient outcomes; mandated by Medicaid and Medicare for home care agencies
SBAR
Situation-Background-Assement-Reccomendation: a technique providing a framework for sommunication btwn members of the healthcare teamabdout a patient’s condition.
SOAP note
Method of organizing charting entries so that each entry includes subjective, objective, assesment, and planning information.
TeamSTEPPS
Team strategies and Tools to Enhance Performance and Patient Safety; a saftey curriculum designed to improve patient outcomes by cultivating teamwork among healthcare providers.
Self-efficacy
individual’s belief in ability to influence his own health
