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level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
AuditorsPeople appointed to examine patient charts and health records to access quality of care
Chart(Health care record) legal record thats used to meet many demands of health accreditation, medical inc, legal system
ChartingProcess of recording info on patient chart
Recording/ documentingProcess of adding written info to the chart (usually at prescribed intervals
Charting by exceptionRecording only new data or changes in patients status or care(charting the exceptions to the previously recorded data
Computers on wheels (COW)POC systems housed on wheeled carts
Point-of-care (POC)Computer electric health record systems that are located at the patients bedside
DatabaseLarge store bank information, as in forming the patient’s nursing diagnoses
Diagnoses-related groupClassifies patients by age,diagnosis, surgical categorías used to predict the use of hospital resources, include hospital stay
Electronic health recordAn electric patient record designed for health info exchaned between facilities
InformaticsStudy of information processing
ISBAR (Identification, situation ,background, assessment, and recommendation)A method of communication among health care workers and a part of documentation of communication that has occurred among health care staff.
Kardex(rand)System that is used by some facilities to consolidate patient orders and care needs in a centralized, concise way
Narrative chartingRecording of patient care in descriptive form
NomenclatureA classified system of technical or scientific names and terminology
Nursing care planOutlines the proposed nursing care base on the nursing assessment and the identified patient problems to provide continuity of care
Nursing notesForm on the patients chart on which nurses record their observation, the care given, and the patients responses
Patient portalOnline system through a healthcare facility that provides a patient with access to their own health information, corresponding w/ providers logging of appointments, etc
Peer reviewAn appraisal by professional coworkers of equal status
Personal health record (PHR)Extension of the EHR that allows patients to input their info into an electric data base (EHR=Electric health records)
Problem listPrioritized master list of patients active, inactive, temporary and at-risk medical or other problems; serve as an index to the rest of the record
Problem-oriented medical record (POMR)Organized according to the scientific problem-solving system or method
Quality assurance, assessment, and improvmentAn audit in health care that evaluates services provided and results achived compared with accepted standards
SOAPEIs the briefer adaptation of the charting format for the POMR(problem-oriented medical record)
SOAPIERAn acronym for seven different aspects of charting (specific problems, only necessary parts)
Traditional(block) chartDivided into sections/ blocks (specific sections- admissions data, physicians order, history and physical exam etc
Electric medical recordsElectronic patient record designed for health info exchange only within a facility