Nursing Documentation and Reporting Notes

These flashcards cover key terminology and concepts related to nursing documentation and reporting.

Documentation

A written or electronic legal record of all pertinent interactions with the patient.

Confidentiality

The responsibility of keeping patient information private and secure.

Patient Rights

Patients have the right to access, update, and request restrictions on their health records.

SOAP Note

A method of documentation that includes Subjective, Objective, Assessment, and Plan.

ISBARR

A communication tool that stands for Identity, Situation, Background, Assessment, Recommendation, and Read back.

Verbal Orders

Instructions given verbally by a physician or NP that must be accurately recorded and verified.

Electronic Health Records

Digital version of patients' paper charts that are real-time records of patient information.

Focus Charting

A nursing documentation method focusing on key patient issues by documenting Data, Action, and Response.

Charting by Exception

A documentation method that records only deviations from the norm, reducing redundancy.

Legal Document

Patient health records are considered legal documents that must be complete, accurate, and timely.

Clinical Research

Investigation aimed at discovering or validating treatment methods through documented patient interactions.

Nursing Care Plan

A document that outlines the patient's care strategy, based on nursing assessments and diagnoses.

Progress Notes

Documentation that tracks the patient's treatment progress and response to interventions.

Home Health Care Documentation

Records pertaining to the care provided to patients in their homes, focusing on patient education and management.

Bedside Shift Report

A method of communication during change of shift that involves the patient and emphasizes current patient needs.