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Flashcards in Unit 2 Test Deck (107)
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91

SOAP - Subjective, objective, assessment, plan
PIE -Problem, intervention, evaluation

Problem oriented charting

92

DAR- Data, action, response

Focus charting

93

Documenting deviations from established norm ;reduces documentation time/highlights changes; Flow records specific to disease; usually kept at bedside; does not always paint the picture

Charting by exception

94

Interdisciplinary care plan that includes problems intervention and expected outcomes within an established timeframe; DRGs

Critical pathways

95

Detailed form; Guides nurse through holistic care; provide the claimant embarrassment

Admission database

96

Allow you to quickly/easily enter assessment data i.e. vital , meals, ADLs; notes for abnormal

Flow sheet

97

Have activity and treatment section; a nursing care plan Demographics, meds ,diagnosis and rate of fluids included

Kardex

98

On paper/PC; list medicine/time/history; must be verified for accuracy. Read everything

MAR medication administration Record

99

Specialty that integrates nursing science computer science and information science to manage and communicate data information and knowledge and nursing practice

Nursing informatics

100

Support the way we function ;support/enhance nursing practice

Two goals of nursing informatics

101

Increase of time spent with patients, better access to information, enhanced quality of documentation, reduced errors of omission, lower hospital costs, increased nurse job satisfaction, compliance with requirements of accrediting agencies, development of a common clinical database

Advantages of nursing informatics system

102

Secure reliable in real time, episode of/longitudinal, primary information resources, evidence-based practice, CQI UR risk management and performance management, reimbursement, research, clinical trials

Attributes of an Electronic health record

103

Ranking patient based on need used for staffing

Acuity

104

Sharing essential information about the patient or changes in their condition; The bedside rounding

Change of shift Report

105

Use of SBARidentify self and validate the message

Telephone report

106

Repeat order back to healthcare provider; follow agency policies ;verified by the physician within 24 hours

Telephone/verbal orders

107

Must document who you spoke to

Transfer reports