Documentation and Charting Vocabulary (Nursing Notes)

Vocabulary flashcards covering key terms from the lecture on documentation practices, confidentiality, and electronic records.

Electronic Health Record (EHR)

Lifetime electronic record that consolidates data across encounters to support communication, care coordination, and patient safety.

Electronic Medical Record (EMR)

Electronic record of a single encounter or admission; not intended to be a lifetime record across multiple facilities.

HIPAA

Health Insurance Portability and Accountability Act; protects patient privacy and dictates how health information is stored, accessed, and shared.

Do-not-use abbreviations (Joint Commission)

A list of abbreviations prohibited in charting to prevent misinterpretation; write terms in full instead.

Flow sheet

Graphic, system-based record for routine data (vital signs, intake/output); allows entry by exception (e.g., WDL/WNL).

SOAP note

Documentation format with four parts: Subjective, Objective, Assessment, Plan; used to organize provider notes.

Narrative note

Free-text, story-like chart entry used in nursing; includes date/time, subjective and objective data, interventions, and follow-up.

Admission nursing history form

Baseline information collected at admission to establish the starting point for care.

Care plan

Standardized plan based on diagnosis; can be individualized with patient-specific symptoms and interventions.

Discharge summary

Documented summary at discharge including medications, follow-up care, referrals, and contact information.

Telephone order (TO)

Order given by phone; should be read back, may require cosignature, used only when necessary.

Verbal order (VO)

Oral order; should be read back and cosigned; may require two-person verification in some settings.

Read-back

Process of repeating orders to verify accuracy with the provider.

Cosign

Provider's signature to verify an order entered by another clinician.

Barcode medication administration (BCMA)

Bedside scanning to verify patient identity, medication, and dose to prevent medication errors.

CAUTI

Catheter-associated urinary tract infection; a nurse-sensitive indicator.

CLABSI

Central line-associated bloodstream infection; a nurse-sensitive indicator.

Hospital-acquired conditions (HAC)

Conditions acquired in the hospital that may not be reimbursed; 11 total; 4 nurse-sensitive: stage III–IV pressure injuries, falls with injuries, CAUTI, CLABSI.

Head-to-toe assessment

Comprehensive physical assessment from head to toe at admission or as needed.

Focused assessment

Targeted assessment focusing on a specific problem or symptom.

Nursing informatics

Specialty combining nursing science with computer science and information management to improve data use and patient safety.

Objective documentation

Descriptive, factual, observable data; avoid subjective language; use exact measurements and quotes only for patient statements.

Military time (24-hour clock)

Time documented in four digits with no colon (e.g., 1410) to reduce AM/PM ambiguity.

Protected health information and confidentiality

Discuss patient information only with the care team; protect passwords; restrict access; avoid including identifiers in nonclinical contexts.

Incident/occurrence report

Internal report for organizational improvement; not part of the patient chart; document objective findings and follow-up without referencing the incident report in the medical record.