Foundational Concepts of Nursing Practice: Collaboration, Informatics, and Documentation

Set of flashcards covering the foundational nursing concepts of collaboration, informatics, and documentation, focusing on definitions and key terms relevant to nursing practice.

Collaboration

Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Informatics

The use of information technology to improve the quality, efficiency, or delivery of health care, and the managing and processing of information necessary to make decisions.

Documentation

The act of recording patient status and care, which can be written, electronic, or hybrid and applies to both inpatient and outpatient settings.

QSEN

Quality and Safety Education for Nurses, focusing on preparing nurses with the competencies necessary to improve quality and safety in healthcare.

ANA Standards of Professional Performance

The American Nurses Association standards that outline the role of registered nurses in collaborating with healthcare consumers and key stakeholders.

Healthcare Teams

Organized groups based on function where members see patients according to their needs and pertinent tasks.

SOAPIE Charting

Charting technique that includes Subjective, Objective, Assessment, Plan, Intervention, Evaluation, and Revision components.

Interprofessional Healthcare Team

A team of healthcare professionals from various fields, working together to meet the needs of patients.

Clinical Decision-Making

The process by which healthcare providers make assessments and decisions based on patient data.

Electronic Health Record (EHR)

A digital version of a patient's paper chart, enabling improved access to information and communication among healthcare providers.