fund ch 17 terms

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fund ch 17 terms
2013-10-07 18:02:36
100 exam three

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  1. change of shift report
    communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped.
  2. charting by exception (CBE)
    shorthand method for documenting patient data that is based on well defined standards of practice; only exceptions to these standards are documented in narrative notes
  3. flow sheet
    graphic record of abbreviated aspects of patient's condition (vital signs, routine aspects of care)
  4. focus charting
    a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of it uses the data (D), action (A), response (R) format
  5. graphic sheet
    form used to record specific patient variables
  6. incident report
    tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor
  7. narrative notes
    progress notes written by nurses in a source oriented record
  8. patient record
    a compilation of a patient's health information; the only permanent legal document that details the nurse's interactions with the patient.
  9. personal health record (PHR)
    information sheets that contain the individual medical history, including diagnoses, symptoms, and medications.
  10. PIE charting
    documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number., worked up using the problem (P), intervention (I), evaluation (E), format, and evaluated each shift.
  11. problem oriented medical record (POMR)
    documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes
  12. progress notes
    any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes.
  13. variance charting
    documentation method in case management that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate.