actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the healthcare team toward its resolution
to consult with someone to exchange ideas or to seek information, advice, or instructions
proces in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution
case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be preformed, and the sequence and timing of those interventions
description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals
written, legal record of all pertinent interventions with the patient - assessments, diagnoses, plans, interventions, and evaluations
electronic medical record (EMR)
computer based records or data that can be distributed among many caregivers in a standardized format
minimum data set
a standard established by healthcare institutions that specifies the information that must be collected from every patient
specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing care
OASIS (outcome and assessment information set)
assessment instrument representing core items of a comprehensive assessment for adult non maternity home care patients and forms the basis for measuring patient outcomes for the purpose of improving the quality of care that is provided.
process of sending or guiding someone to another source for assistance
consistent, clear, structured, and easy to use method of communication between healthcare personnel; it organizes communication by the categories of Situation, Background, Assessment, and Recommendations.
method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)
source oriented record
documentation system in which each healthcare group records data on its own separate form.