Fundamentals of Nursing: Documentation, Ethics, EBP, Leadership, and Informatics

Vocabulary practice flashcards generated from nursing lecture content covering health records documentation, ethics and legal standards, evidence-based practice, nursing leadership, and healthcare informatics.

Diagnostic-Related Groups (DRGs)

Categories used by healthcare organizations where accurate documentation is required to receive financial reimbursement.

Hand-Off Report

The transfer of patient-specific information from one caregiver to another—which may be oral, written, recorded, or printed—to promote continuity of care and collaborative problem solving.

Incident Report

A document generated when an unusual and unexpected event occurs involving a patient, visitor, or staff member; it is used for immediate accurate recording and is not part of the medical record.

Comprehensive Flowsheet

A structured documentation interface used in health records to monitor patient vitals, intake, output, and routine shift measurements at set time intervals.

Ethics

Standards of moral conduct in a society.

Code of Ethics

A formal document that defines the values, morals, and standards guiding practice in a specific discipline or profession.

Bioethics

The study of ethical and philosophical issues in biology and medicine.

Moral Distress

The anguish that healthcare professionals experience when their basic beliefs of right and wrong or ethical principles are challenged.

Moral Resilience

The capacity of an individual to sustain or restore integrity in response to moral complexity, confusion, distress, or setbacks.

Deontology

A duty-based ethical theory.

Four D's of Negligence

The four required legal elements to establish negligence: Duty, Dereliction, Damages, and Direct cause.

Basic Research

A type of nursing research designed to generate theories.

Applied Research

A type of nursing research designed to test theories in different situations with different populations.

Clinical Research

A type of nursing research designed to test theories about the effectiveness of interventions.

Research Utilization

The application of research findings to improve clinical practice.

Evidence-Based Practice (EBP)

An approach to care that integrates theoretical background, clinical judgment, and patient preferences.

Hierarchy of Evidence Levels

A pyramid structure rating research evidence from Level I (systematic review or meta-analysis of RCTs) down to Level VII (opinions of authorities or reports of expert committees).

PICO(T)

A mnemonic used to formulate clinical research questions: Population, Intervention, Comparison, Outcome, and Timeframe.

Leadership

The ability to influence, guide, or direct others; focuses on relationships and does not require a formal position of authority.

Management

The process of coordinating others and directing them toward a common goal; focuses on tasks and holds a formal position of authority.

Autocratic Leadership

A leadership style in which the leader exerts complete control over subordinates.

Democratic Leadership

A leadership style where employees are encouraged to participate in decision-making processes.

Laissez-Faire Leadership

A permissive leadership style where employees are self-motivated by internal desires to perform well.

Bureaucratic Leadership

A leadership style where employees are motivated primarily by external forces and rigid organizational rules.

Fayol's Functions of Management

The four core managerial functions defined by Henri Fayol: Planning, Organizing, Directing, and Controlling.

Five Rights of Safe Delegation

The delegation standard ensuring Right task, Right circumstances, Right person, Right direction or communication, and Right supervision.

Critical Needs Priority

Immediate patient priorities required to prevent harm, including changes in level of consciousness (LOC), new-onset chest pain, and respiratory distress.

Informatics

A broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.

Nursing Informatics

The specialty that integrates health information systems to support nursing practice.

Point of Care Technology

Bedside technological tools that reduce potential error, support clinical assessment, and improve data communication.

Data to Wisdom Continuum

The structural processing model that moves from Data Organization (shallow/rule-based knowledge), to Information (midlevel knowledge), to Knowledge (deep knowledge), to Wisdom (appropriate use of knowledge).

TIGER Initiative

Technology Informatics Guiding Education Reform; an initiative outlining essential 21st-century nursing skills in management, leadership, education, collaboration, informatics design, and IT policy.

Nursing Minimum Data Set (NMDS)

A standardized system collected to capture essential nursing data across healthcare settings.

Health on the Net Foundation (HON)

An organization providing standard accreditation and guidelines for trustworthy health-related internet sites.