Documentation, Electronic Health Records, and Legal Considerations in Nursing

Vocabulary flashcards covering documentation methods, electronic health record systems, cybersecurity, standardized terminology, and legal regulations from the lecture.

Electronic Health Record (EHR)

A digital compilation of a client's medical information and health data, including demographics, vital signs, medical history, diagnoses, treatments, medications, allergies, immunizations, and laboratory/radiology reports.

Ambient AI documentation

A technology that functions passively in the background capturing clinical information from environmental cues without requiring direct user input, producing a structured clinical note for healthcare provider review and validation.

Source-oriented medical record

A traditional medical record format divided into specific discipline-based sections or sources, such as progress notes, nurse notes, laboratory reports, and diagnostic testing.

Problem-oriented medical record (POMR)

A comprehensive documentation system developed by Lawrence L. Weed consisting of four components: a database, a chronological problem list, an initial plan, and progress notes written in SOAP format.

SOAP format

A widely used documentation guide within the POMR that structures clinician observations into Subjective data, Objective data, Assessment, and Plan.

PIE model

A simplified documentation approach focused on the nursing process that records Problems using nursing diagnoses, Interventions, and Evaluations along with an ongoing plan of care.

Focus charting

A documentation method that centers on a specific client healthcare problem or condition change using three items: Data, Action, and Response.

Charting by exception (CBE)

A documentation system that records only unexpected or unusual findings based on standardized protocols and explicit assessment norms.

Incident Response Plan (IRP)

A facility plan that provides step-by-step instructions during a cybersecurity event, specifying task responsibilities and procedures to restore systems and workflow safely and quickly.

FACT framework

A structured documentation framework emphasizing that entries must be Factual, Accurate, Complete, and Timely.

a.c.

Medical abbreviation meaning before a meal.

ad lib.

Medical abbreviation meaning at liberty, indicating the client can move around freely.

b.i.d.

Medical abbreviation meaning twice a day.

NPO

Medical abbreviation meaning nothing by mouth.

PRN

Medical abbreviation meaning as needed.

STAT

Medical abbreviation meaning at once or immediately.

Institute for Safe Medication Practices (ISMP)

An organization devoted to preventing healthcare errors that maintains a list of error-prone, dangerous medical abbreviations in conjunction with The Joint Commission.

Verbal orders

Spoken healthcare orders communicated aloud by authorized prescribers, which should be limited to urgent or emergency situations due to risk of medication error.

Closed-loop communication

A verbal order safety process in which the recipient transcribes the order and repeats it back to the prescriber to obtain confirmation prior to implementation.

Health Insurance Portability and Accountability Act (HIPAA)

A 1996 federal law establishing national standards for protecting the privacy and security of clients' protected health information.

HIPAA Privacy Rule

A set of federal regulations taking effect in 2003 that governs the use and disclosure of protected health information to guarantee client confidentiality.

Health Information Technology for Economic and Clinical Health (HITECH) Act

A 2009 federal law that encouraged healthcare facilities to install CPOE systems to enhance documentation reliability and client safety.

Computerized Provider Order Entry (CPOE)

An electronic ordering system that reduces prescribing and transcription errors by incorporating safety checks, decision support tools, and interaction alerts.