Fond. Unit 2 Study Guide (1)

Vocabulary flashcards covering documentation standards, communication frameworks, nursing process phases, clinical judgment models, and care transitions.

FACT Charting

An acronym for core documentation standards standing for Factual, Accurate, Complete, and Timely.

Late Entry

A charting entry made for omitted documentation that must be clearly labeled as "Late Entry", state the exact date and time the event actually occurred, and be signed and dated.

Incident Report

An agency form completed for unexpected occurrences (such as patient falls, medication errors, or needlestick injuries) that is maintained separately from the patient record and never documented in the chart.

SBARR

A standardized communication framework representing Situation, Background, Assessment, Recommendation, and Read back, used during provider updates, shift handoffs, and interagency transfers.

Read Back

The final step of SBARR communication and order verification where the receiving nurse repeats information or prescription details back to the provider to ensure completeness and accuracy.

Charting by Exception (CBE)

A documentation method where only unexpected, unusual, or abnormal findings outside defined standard parameters are recorded after a baseline assessment.

Source-Oriented Medical Record

A traditional healthcare record format utilizing narrative, story-telling charting to describe patient encounters chronologically.

Problem-Oriented Medical Record

A medical record structure organized around patient problems, most commonly utilized by physicians via SOAP (Subjective, Objective, Assessment, Plan) charting.

PIE Model

A nursing documentation format organized around Problem, Intervention, and Evaluation that aligns directly with the nursing process.

Focus Charting

A client-centered documentation system focused on specific nursing diagnoses, client status, or events, structured around Data, Action, and Response (DAR).

Subjective Data

Information gathered directly from the client's verbal statements regarding their feelings, perceptions, or symptoms (e.g., pain reports or nausea).

Objective Data

Observable and measurable clinical data collected using the nurse's senses, physical examination, or diagnostic equipment (e.g., vital signs or wound dimensions).

Primary Data Source

Information gathered directly from the patient or through the nurse's own direct observations and physical assessment.

Secondary Data Source

Assessment information obtained from secondary individuals or references, including family members, caregivers, health records, or other care providers.

Initial Comprehensive Assessment

A complete head-to-toe physical and historical assessment performed exclusively by the RN upon admission to establish a baseline for care.

Focused Assessment

A targeted clinical assessment performed to evaluate a specific body system or problem, especially when a patient is disoriented, critically ill, or unable to respond fully.

Clinical Judgment

The observed outcome of critical thinking and decision-making that utilizes nursing knowledge to assess clinical situations, identify priorities, and generate evidence-based solutions.

Clinical Judgment Action Model (CJAM)

The NCSBN process framework consisting of six sequential functions: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, and Evaluate Outcomes.

SMART Goals

Patient-centered plan of care objectives structured to be Specific, Measurable, Attainable, Relevant, and Time-oriented.

Intraagency Transfer

The transfer of a patient from one unit or department to another within the same healthcare facility (e.g., moving from the Emergency Room to a Medical-Surgical unit).

Interagency Transfer

The relocation of a patient from one distinct healthcare facility to another (e.g., moving from an acute hospital to a long-term care facility).

Discharge Planning

A systematic, multidisciplinary planning process that begins at admission to coordinate continuous care and instruction after the patient leaves the facility.

Against Medical Advice (AMA)

The official facility process and documentation required when a competent patient chooses to leave a healthcare facility prior to receiving a provider's discharge order.

Medication Administration Record (MAR)

A paper or electronic record detailing prescribed medications, dosages, routes, schedules, and nursing charting of drug administration.

Maslow's Hierarchy of Needs

A prioritization model applied in nursing practice establishing that physiological needs must be satisfied before addressing safety, security, or psychosocial concerns.