Glossary of Nursing Documentation
Other Decks By This User
- What is a Change-of-Shift report?
- a report given to nurses on the next shift.
- Define a Chart.
- A chart is a formal, legal document that provides evidence of a client's care.
- Define Charting.
- Charting is the process of making an entry on a client's record.
- Define CBE.
- (CBE) is Charting By Exception- a documentation system in which only significant findings or exceptions to norms are recorded.
- What is another name for "client record"?
- Define Discussion.
- Discussion - an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
- What are some synonym for documenting?
- Charting, Recording.
- What is a Flowsheet?
- A flowsheet is a record of the progress of a specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form.
- A method of charting that uses key words or foci to describe what is happening to the client is known as what?
- Focus charting
- Define Kardex.
- Kardex is the trade name for a method that makes use of a series of cards to soncisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date.
- What do we call a descriptive record of client data and nursing interventions, written in sentences and paragraphs?
- We this Narrative charting.
- What is PIE?
- PIE is an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions.
- What is POMR?
- POMR is an acronym that stands for Problem Oriented Medical Record.
- Describe POMR.
- In POMR data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information.
- What is a synomyn for POMR?
- A syn. for POMR is POR shich stands for Problem-Oriented Record.
- Define Progress notes.
- Progress notes are chart entries made by a variety of methods and by all health professoinals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes.
- What is a Record?
- A record is a written communication providing formal, legal documentation of a client's progress.
- Define Recording.
- the process of making written entries about a client on the medical resord.
- Describe a good Report?
- whether oral or written, it should be concise, including pertinent information but no extraneous detail
- What is SOAP besides something we use to wash our hands with?
- An acronym for a charting method that follows a recording sequence of Subjective data, Objective data, Assessment, and Planning.
- What type of recording is done where each person or department makes notations in a separate section or sections of the client's chart?
- Source'oriented record.
- What is a variance?
- A variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame.
You must Login or Register to add cards