fund ch 17 terms
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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.
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
graphic record of abbreviated aspects of patient's condition (vital signs, routine aspects of care)
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
form used to record specific patient variables
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
progress notes written by nurses in a source oriented record
a compilation of a patient's health information; the only permanent legal document that details the nurse's interactions with the patient.
personal health record (PHR)
information sheets that contain the individual medical history, including diagnoses, symptoms, and medications.
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.
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
any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes.
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.
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