week 2 lecture notes

Vocabul ary flashcards covering key terms from Week Two topics: Documentation, ISBAR/SBAR, EHR/PHR, nursing processes, and communication.

Electronic Health Record (EHR)

A digital version of a patient’s chart used at the point of care, often integrated with tools like CPOE and CDSS; supports documentation across care settings and may replace paper charts.

Personal Health Record (PHR)

A patient-maintained record of health information that patients can view and sometimes update.

Computers on Wheels (COWS)

Mobile computers used at the bedside to access and document patient information at the point of care.

HIPAA

Health Insurance Portability and Accountability Act; governs privacy, security, and access to personal health information.

Record Ownership

Records generally belong to the healthcare provider; patients may view or obtain records with consent; patient portals may enhance access.

Paper Chart

Traditional, paper-based patient records before digital systems.

Hybrid System

A mix of paper and electronic records within a health care facility.

Integrated EHRs

Electronic health records that are coordinated across departments and care settings.

CPOE

Computerized Provider Orders Entry; placing provider orders electronically.

CDSS

Clinical Decision Support System; computer tools that aid clinical decision-making.

NANDA-I

North American Nursing Diagnosis Association International; standardized nursing diagnoses.

NIC

Nursing Interventions Classification; standardized nursing interventions.

NOC

Nursing Outcomes Classification; standardized patient outcomes.

Kardex/Rand

Quick-reference nursing summaries used to organize patient information.

SOAPE

A documentation format: Subjective data, Objective data, Assessment, Plan, and Education.

Focus Charting

Documentation that centers on a focus (problem, concern, or strength) rather than routine progress notes.

Charting by Exception

Documenting only abnormal findings or deviations from defined standards.

POMR

Problem-Oriented Medical Record; organizes data around patient problems with a problem list, database, plan, and progress notes.

Narrative Documentation

Chronological, story-like notes describing patient care.

Traditional Chart

A paper-based or conventional sectioned chart used historically.

24-Hour Patient Care Reports

Daily documentation forms used to capture care provided within a 24-hour period; often linked to acuity.

Acuity Forms

Forms used to document patient care needs and assist staffing decisions based on patient acuity.

Incident Reports

Reports filed for unexpected or unusual events; used for quality improvement and safety analysis.

Discharge Summary

A summary of the patient’s hospital course and status at discharge.

OBRA

Omnibus Budget Reconciliation Act (1987); regulates standards for resident assessment and care planning in long-term care.

DOH

Department of Health; state-level regulatory body governing documentation standards and frequency of nursing records.

Home Health Care Documentation

Documentation guidelines for home health to ensure reimbursement and coordination of services.

Clinical Pathways

Multidisciplinary, evidence-based care plans guiding care for specific conditions and projected length of stay.

Variance (in clinical pathways)

A deviation when a patient does not achieve the projected outcomes.

NANDA-I, NIC, NOC Relationship

Standardized language for diagnoses (NANDA-I), interventions (NIC), and outcomes (NOC) in nursing care.

Six Phases of the Nursing Process

Assessment, Diagnosis, Outcomes identification, Planning, Implementation, Evaluation.

Assessment Data

Types of data: Subjective and Objective; cues; primary and secondary sources; collected via interview and physical exams.

Patient Problem Statement

NANDA-I nursing diagnosis; includes signs/symptoms, contributing factors, defining characteristics; can be actual or potential.

Collaborative Problems

Health problems requiring coordinated care between nursing and other professionals; distinct from medical diagnoses.

Medical Diagnosis

A diagnosis made by a physician or other licensed clinician; differs from a nursing diagnosis.

Goal Identification

Measurable, patient-centered outcomes describing desired behavior within a time frame.

Planning

Setting priorities and selecting nursing interventions to address the nursing diagnosis; communicates through the care plan.

Priority Setting

Ordering patient problems by importance, often with physiologic needs taking precedence.

Nursing Interventions

Actions aimed at achieving desired patient outcomes; may be physician-prescribed or nurse-prescribed.

Writing Nursing Interventions

Interventions should be clear, specific, and include subject, action verb, and qualifiers.

Nursing Care Plan

Written document outlining nursing diagnoses, goals, and planned interventions to achieve outcomes.

Linear Care Plans vs Concept Maps

Linear plans use columns (NANDA-I, goals, interventions); concept maps visualize relationships among diagnoses, goals, and actions.

Implementation

Putting the care plan into action using evidence-based interventions; performed safely and timely.

Evaluation

Assessing whether patient goals were achieved; outcomes may be achieved, not achieved, or partially achieved.

Evidence-Based Practice

Clinical practice grounded in nursing research and best available evidence.

Critical Thinking

Deliberate, purposeful thinking; questioning information; using a knowledge base to make decisions and solve problems.

Verbal Communication

Communication using spoken or written words; includes denotative and connotative meanings and jargon.

Nonverbal Communication

Communication through facial expressions, body language, voice, posture, eye contact, and gestures.

Consistency of Verbal and Nonverbal Communication

Nonverbal messages should align with spoken words to avoid mixed signals.

Assertive Communication

A respectful, confident style that considers both patient needs and nurse rights; often the most therapeutic.

Therapeutic Relationship

Caring, sincere, empathetic, and trustworthy nurse-patient relationship with professional boundaries.

Therapeutic Communication Techniques

Techniques such as listening, silence, touch, open-ended questions, restating, paraphrasing, clarifying, focusing, reflecting, summarizing, and humor.

Nontherapeutic Communication

Communication that blocks the therapeutic relationship, e.g., false reassurance, giving unsolicited advice, or judging.

Barriers to Communication

Obstacles like false reassurance, automatic responses, language barriers, and cultural differences that hinder effective exchange.

Clock-Face Communication

Alternative method for non-speaking patients using messages placed around a clock face to indicate choices.

Computer-Assisted Communication

Techniques allowing patients to communicate via computer interfaces.

Eye Blinks as Yes/No

A predetermined system where blink patterns indicate yes or no responses.

Lip-Reading

Interpreting spoken words by reading the speaker’s lip movements.

Magnetic Boards with Letters

Board with movable letters used for spelling out messages.

Paper and Pencil (Magic Slate)

Simple writing tools for patients to communicate needs.

Picture Board

Board of pictures or symbols patients point to for communication.

Sign Language

System of hand and finger signals used to communicate, especially with hearing-impaired patients.

Word or Picture Cards

Cards with words or pictures patients select to express needs.