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NUR 152 Final Exam > Charting > Flashcards

Flashcards in Charting Deck (17)
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1

EMR

Electronic Medical Record
record of one episode of care

2

EHR

Electronic Health Record
longitudinal record of health

3

proper documentation

clear
accurate
accessible
timely
factual
nonjudgmental
proper grammar
date, time, signature

4

Narrative

time consuming
lengthy
traditional

5

Problem Oriented Medical Record

organizing documentation to place primary focus on patient's individual problems
SOAP, SOAPIE, DAR, PIE

6

PIE

Problem
Intervention
Evaluation

7

APIE

Assessment
Intervention
Evaluation

8

SOAP

Subjective
Objective
Assessment
Plan

9

SOAPIE

Subjective
Objective
Assessment
Plan
Intervention
Evaluation

10

DAR

Data
Action
Response

11

CBE

Charting by Exception
records only abnormal and significant data

12

flow sheets

can be converted to a graph
used to document routine care: vitals, meds, I/O

13

HIPAA

Heath Insurance Portability and Accountability

14

SBAR

Situation
Background
Assessment
Recommendation

15

advantages of electronic charting

improves quality of nursing documentation
enhances patient safety
enhances communication

16

disadvantages of electronic charting

computer and software failure
inaccessible in power outages

17

DRG

diagnosis related groups