Nursing Fundamentals and Patient Care Documentation

This collection of flashcards focuses on key nursing and documentation concepts essential for understanding patient care and successful nursing practice.

Documentation

The process of recording nursing information about nursing care in health records.

Purpose of Medical Records

A valuable source of data for health care teams, facilitating legal records, funding management, and education.

Legal Documentation

Accurate documentation serves as a defense against legal claims associated with nursing care.

EHR

Electronic Health Record, a digital version of patient data found in traditional records.

EMR

Electronic Medical Record, a legal record describing a patient's encounter in a health care setting.

Common Charting Mistakes

Errors such as failing to record pertinent health information, mixing up charts, and inaccurate transcriptions.

Patient Records

Used for clinical research studies to investigate nursing interventions.

Interprofessional Communication

Sharing patient health information among healthcare team members.

Confidentiality

Protecting patient's private health information both inside and outside the workplace.

PIPEDA

Personal Information Protection and Electronic Documents Act, federal legislation to protect personal health information.

Flow Sheets

Forms used to record current patient information for quick and easy entry.

SOAP

A method of documentation standing for Subjective, Objective, Assessment, and Plan.

Problem-Oriented Medical Records

A system organizing documentation based on the patient's issues.

Tactile Fremitus

Palpable vibrations felt on the chest wall when a person speaks.

Normal Heart Sounds

Sounds produced by the closure of the heart valves during the cardiac cycle.

Subjective Data

Information provided by the patient regarding their feelings and symptoms.

Objective Data

Information gathered through physical examination or diagnostic tests.

General Survey

An overall assessment of the patient that includes appearance, posture, and mobility.

Cultural Sensitivity

Awareness and respect for cultural differences in health care.

Health Assessment

An evaluation that includes both subjective and objective data to determine a patient's health status.

Clinical Decision Support System (CDSS)

A computerized tool used to aid clinical decision making.

Nursing Diagnoses

Clinical judgments about individual, family, or community responses to actual or potential health problems.

Betty Neuman's Systems Model

A holistic approach to nursing care that considers the patient as a system affected by stressors.

Holistic Care

An approach to health care that includes the emotional, social, and spiritual aspects of a patient.

Cognitive Assessment

Evaluation of a patient's thinking processes and abilities.

Vital Signs

Measurements of the body's basic functions, including temperature, pulse, respiration, and blood pressure.

Symptom Analysis

A detailed examination of the nature, location, and duration of a patient's symptoms.

Patient Education

Providing information and resources to improve a patient's health literacy.

Patient Advocacy

Supporting and promoting the interests of patients in healthcare settings.

Informed Consent

The process of providing patients with the information they need to understand a procedure's risks and benefits.

Health History

A comprehensive record of a patient's past and present health status.

Asthma Pathophysiology

The mechanism through which asthma affects respiratory function and airflow.

Diabetes Management

Strategies to control blood sugar levels and manage symptoms of diabetes.

Chronic Illness

A long-term health condition that may not have a cure but can be managed.

SOAPIE Notes

Documentation format that extends SOAP with Intervention and Evaluation.

Patient Safety

The prevention of errors and adverse effects to patients associated with health care.

Clinical Pathways

Structured multidisciplinary plans that detail essential steps in patient care.

Quality Improvement

Ongoing efforts to improve health services and outcomes.

Evidence-Based Practice

Integrating clinical expertise with the best available empirical evidence and patient values.

Patient Identification

Ensuring proper identification of patients to prevent medical errors.

Incident Reporting

Documentation of events that resulted in harm or have the potential to cause harm.

Abbreviations in Nursing

Standardized shorthand used in healthcare documentation to assist with communication.

Audit Trail

Records that trace the history of the documentation process for accountability.

Referral Process

The process of directing a patient to a specialist or another healthcare provider.

Interdisciplinary Teamwork

Collaboration among various healthcare professionals to provide high-quality patient care.

Compassionate Care

Providing care that is sensitive to the emotional needs of patients.

Patient-centered Care

Approach that respects and responds to patient preferences, needs, and values.

Racism in Healthcare

Discrimination based on race that adversely affects patient outcomes.

Ethics in Nursing

Principles that guide nursing practice, including autonomy, beneficence, and justice.

Legal and Ethical Responsibilities

Obligations that healthcare providers have with respect to laws and ethical principles.

Clinical Guidelines

Systematically developed statements to assist provider and patient decisions about appropriate health care.

Documentation Standards

Regulations and guidelines that govern how health records are created and maintained.

Root Cause Analysis

A systematic process for identifying the root causes of problems.

Safety Culture

A proactive approach to patient safety focused on creating an environment of safety in healthcare.

Medication Reconciliation

A process of ensuring a patient's medication list is accurate and complete.

Skilled Nursing Facility

A healthcare facility that provides 24-hour nursing care.

Telehealth

Use of telecommunication technology to provide medical care and information.

Chronic Care Model

A framework for organizing care for people with chronic conditions.

Comprehensive Health Assessment

A thorough evaluation of a patient's health history and physical examination.

Health Promotion Activities

Actions that help individuals and communities improve their health.

Patient Room Assignment

The process of placing patients into hospital rooms based on their needs.

Discharge Planning

A process that ensures patients have a plan to continue care after leaving the healthcare facility.

Referral Forms

Documents used to refer patients to specialists or other services.

Mental Health Assessment

An evaluation to determine a patient's mental health status.

Substance Abuse Screening

Assessing patients for misuse of drugs or alcohol.

Glasgow Coma Scale

A scale used to assess a person's level of consciousness and response.

Nutritional Assessment

Evaluation of a patient's dietary habits and nutritional status.

Health Literacy

The ability of patients to understand and use health information.

Decision-Making Capacity

A patient's ability to make informed health care decisions.

Informed Consent Process

The process of ensuring that patients have adequate understanding to make health decisions.

Fluid and Electrolyte Balance

Managing the levels of fluids and electrolytes in the body.

Pain Management Protocols

Strategies to effectively control pain in patients.

Patient Self-Management

Patients taking an active role in their health care.

Patient Satisfaction Surveys

Tools used to measure patients' satisfaction with health services.

Chronic Obstructive Pulmonary Disease (COPD)

A group of lung diseases that block airflow and make breathing difficult.

Heart Failure Management

Strategies to monitor and treat patients with heart failure.

Hipaa Regulations

Laws to protect patients' health information from disclosure without their consent.

Risk Assessment Tools

Instruments used to evaluate patient risks for various outcomes.

Crisis Intervention

Immediate and short-term psychological care aimed at assisting individuals in a crisis.

Community Health Needs Assessment

A study to identify health needs and priorities within a community.

Culturally Competent Care

Care that is respectful of and responsive to the cultural needs of patients.

Complications of Diabetes

Long-term health issues that arise from poorly managed diabetes.

Nursing Theories

Conceptual frameworks that guide nursing practice and research.

Patient Advocacy Services

Support provided to help patients navigate health care systems.

Predictive Analytics in Nursing

The use of data analysis to predict patient outcomes.

Patient Care Protocols

Detailed plans for providing care to patients in specific health situations.

Readiness for Change Assessment

An evaluation of a patient's willingness to change health behaviors.

Clinical Trial Consent Forms

Documents that inform participants about the details of clinical trials.

Emergency Response Procedures

Protocols to follow during clinical emergencies.

Final Dispositions in Health Care

Outcomes that result from health care interventions.

Benefits of Interdisciplinary Teamwork

Advantages gained from collaboration among different health professionals.

Complementary and Alternative Medicine (CAM)

Non-conventional practices used alongside or instead of traditional medicine.

Stress Management Techniques

Methods to help individuals manage stress effectively.

Patient Participation in Care Decisions

Involvement of patients in discussions regarding their treatment options.

Leadership Styles in Nursing

Different approaches nurse leaders can take to influence teams.

Healthcare Systems Navigation

Guiding patients through the complexities of health care services.

Advance Directives

Legal documents that outline a patient's wishes for medical treatment.

Pain Assessment Tools

Instruments used to evaluate the severity and nature of pain.

Social Determinants of Health

Conditions in which people are born, grow, live, work, and age that affect health.

Infection Control Policies

Guidelines aimed at preventing the spread of infections in healthcare facilities.