Chapter 15 Documentation and communication in the healthcare team
What is a plan of care?
A plan of care should be generated at admission and revised to reflect changes in the patient's condition. 251
SBAR what does it stand for?
Situation Background Assessment Recommendations 255
What are quality assurance memos?
Some facilities use incident reports r/t nursing procedures as a way to evaluate the quality of care. 254
When does a variance occur?
When the patient doesn't proceed along the pathway as planned.251
When was HIPPA invented?
1996 p.243
Audit what is it?
An audit is a review of records. 241
An incident is what?
Any unusually happening such as a fall, med error, malfunction in equipment, or injury to a patient visitor or employee that occurs during the performance of healthcare activities. 254
What is CBE?
Charting by exception permits the nurse to document only those findings that fall outside the SOC and norms that have been developed by the institution. 248
What are clinical pathways
Collaborative pathways or care maps 251
What is CPR related to records?
Computer based personal record 242
What is CPOE?
Computerized Physician (Provider) Order Entry allows authorized providers to enter all orders directly into the computer, electronically communicating orders to the lab, pharmacy, and nursing personnel.
What is eMAR?
Electronic medication administration record interfaces medication orders with pharmacy dispensing and allows direct computer charting of medication admin.242
When do physians order a consult?
Physicians order a consult when a specialist or health team member must provide an expert opinion or specialized care for a patient. 257
What is POC?
Point of care documentation is documentation that takes place as care occurs. 247
What is reporting?
Reporting takes place when two or more ppl share info about patient care, either face to face, by audiotape or voicemail, or by phone. 240
What is RAI?
Resident Assessment Instrument governs documentation in LTC settings. 253
What are flow sheets?
Tables that have vertical and horizontal columns that allow nurses to document routine assessments and procedures. 248
What is TeamSTEPPS?
Team strategies and tools to enhance performance and patient safety- is a safety curriculum designed to improve patient outcomes by cultivating teamwork among HCP. 259
What is the FOCUS system?
The FOCUS system of documentation organizes entries by D data, A action, and R response. 251
What is PIE charting?
The PIE charting system simplifies documentation by incorporating the plan of care into the progress notes. 250
What is the SOAP note?
The SOAP note is a progress note that relates to only one health problem. 249
What is a handoff?
Transfer of care for a patient from one health provider to another , significantly increases the risk of errors. 252
Batch charting wat is it?
Waiting until the end of the shift to record events on several patients.247
OASIS what is it?
outcome and assessment information set... in 2000 the fed govt mandated that home care agencies must use the OASIS in the initial and ongoing assessment of all patients they are for to qualify for Medicare or Medicaid reimbursement. 253
