Chart - ANSWERAlso known as the health care record.
A legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems.
Charting - ANSWERAlso known as documenting and recording.
Involves recording the interventions carried out to meet th...
Chart - ANSWERAlso known as the health care record.
A legal record that is used to meet the many demands of the health, accreditation, medical
insurance, and legal systems.
Charting - ANSWERAlso known as documenting and recording.
Involves recording the interventions carried out to meet the patient's needs. Good quality
documenting reflects nursing process.
Assessment - ANSWERPortion of the nursing process that checks patient's physiological status,
functional status, knowledge, psycho-social well-being, family, and safety.
Usually interviews from patient are done, as well as a history check and physical examination, lab
work and medication records are viewed as well.
Diagnosis - ANSWERPortion of the nursing process that checks a patient's potential ailments based
on assessments.
Plan of Care - ANSWERPortion of the nursing process that defines a goal that the individual will
accomplish. Involves the patient's care plan, their projected length of stay, the standards of care, the
admission assessment data, and staff reports.
Implementation - ANSWERPortion of the nursing process that uses progress notes and patient
rounds and care to determine the progress the individual/patient is making to achieving goals set in
the plan of care.
, Evaluation - ANSWERPortion of the nursing process that uses family interviews, physical assessment,
staff and progress reports, diagnostic tests, and flow sheets to determine whether the treatment of
the plan of care was effective.
Auditor - ANSWERAn individual appointed to examine patient charts and health records to assess the
quality of care. They check to see if all ordered care was charted as given and whether responses to
care plan items were noted.
Peer Review - ANSWERA system or individual that appraises an individual nurse's practice, education,
and research.
Quality Assurance Assessment Improvement - ANSWERAlso known as QAPI
It is an audit in health care that evaluates services provided and the results achieved compared with
accepted standards.
Diagnosis Related Groups - ANSWERAlso known as DRG
A system used by Medicare/Medicaid that classifies patients by age, diagnosis, surgical procedure,
and other categories to predict hospital resources such as length of stay, resulting in a fixed payment.
Nursing Notes - ANSWERForm in a patient's chart where nurses record observations, the care given,
and patient responses.
Electronic Health Record - ANSWERAlso known as EHR
This facilitates delivery of patient care and supports data analysis necessary for coordinating patient
care. It eliminated repetitive entries and allowed more freedom of access.
The EHR is able to move along with the patient if they move from facility to facility.
Electronic Medical Record - ANSWERAlso known as an EMR
Compared to an EHR, the EMR is limited and accessible to qualified individuals within the facility..
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