1165 THURS Week 4 Lecture: Documenting And Reporting Flashcards
Charting by exception
is a system for documenting exceptions to normal illness or disease progression, using a shorthand method of charting what’s usual and normal
Critical care pathway
multidisciplinary plan that outlines the expected course of care for patients with a specific medical condition or undergoing a particular procedure.
DESIGNED TO STREAMLINE RECOVERY
The pathway includes key interventions, activities, and milestones to guide healthcare providers in delivering efficient and effective care.
primary documents communicating a patient’s care plan to the post-hospital care team.
Discharge summary
An _________is an electronic version of a patients medical history, that is maintained by the provider over time
Electronic Health Record (EHR)
_______ is simply a one- or two-page form that gathers all the important data regarding a patient’s condition, in this case diabetes.
The _____ housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met.
flow sheet
documentation method that concentrates on specific, pertinent information related to a particular aspect of a patient’s care.
Concise / targeted approach to recording patient data, emphasizing the essential details, treatment, or response to interventions.
Focus charting
Graphic Record
visual representation of a patient’s vital signs, treatments, assessments, or other relevant information over a specific period.
Health Information Exchange (HIE)
Electronic sharing of patient health information among different healthcare providers and systems.
Used in Handoffs, transfers, or when escalating patient care.
Introduction:
Identify yourself and your role.
Situation: with patient
Background of patient
Assessment of patient
Recommendation: to be done with patient
ISBAR
a _______(MDS) refers to a standardized set of essential information that is systematically collected and maintained for every patient
Minimum Data Set
Documentation where nurses record information about a patient’s care and condition in a paragraph format.
Unlike structured forms or checklists
Narrative notes
More descriptive than checklist notes
This type of charting focuses on recording details surrounding unusual incidents, deviations from the expected course of care, or any noteworthy events that may impact the patient’s well-being
Occurrence chartinf
Outcome and Assessment Information Set (OASIS) is….
a standardized data set used in home health care to assess and measure patient outcomes.
A _____(PHR) in nursing refers to a health information document that is maintained and managed by an individual patient,
Unlike the traditional medical record, which is created and maintained by healthcare providers
Patient health record
PIE charting
Problem, Intervention, and Evaluation charting
Progress notes in nursing are written or electronic documents that provide a detailed, chronological account of a patient’s care, treatment, and response to interventions during a specific period
Usually in this format
Subjective
Objective
Assessment
Plan
Purposeful rounding in nursing…
systematic and intentional approach to regularly checking on patients to ensure their needs are met and to proactively address any potential issues.
Read-back in nursing….
Repeating back what was said to you to ensure correct communication
Actividades
AMB
Ambulatory
Actividades
BRP
Bathroom Privileges
Actividades
CBR
Complete Bed rest
Actividades
OOB
Out of bed
Actividades
up ad lib
Up as desired
Assessment Data
abd
Abdomen
Assessment Data
BP
Blood pressure
Assessment Data
bx
Biopsy
Assessment Data
c/o
Complaints of
Assessment Data
CTA
Clear to ausculation
Assessment Data
dx
Diagnosis
Assessment Data
FUO
Fever unknown orign
Assessment Data
GI / GU
Gastrointestinal
Gastrourinary
Assessment Data
H/A
Headache
Assessment Data
h/o
History of
Assessment Data
HPI
History of Present Illness
Assessment Data
Imp
Impressions
Assessment Data
lt or L with a circle around it
Left
Assessment Data
MAE
Moves all extremeities
Assessment Data
NAD
No apparent distress
