Informatics and Documentation (Chapter 26)

Vocabulary flashcards covering key concepts and terms from the Informatics and Documentation chapter.

Health care record

The written or electronic account of patient data, clinical interventions, responses, and status used for communication among the health care team.

Electronic Health Record (EHR)

A lifetime computerized record of a patient’s health information that can be accessed across encounters and linked across facilities.

SBAR

A structured communication approach: Situation, Background, Assessment, and Recommendation used during handoffs.

ISBARR

SBAR with Readback; SBAR plus an explicit readback step to confirm understanding.

DAR

Data, Action, Response; a documentation format used in nursing notes.

PIE

Problem, Intervention, Evaluation; a documentation format focusing on problems and actions.

SOAP

Subjective, Objective, Assessment, Plan; a standard format for progress notes.

Flowsheets

Per-shift records of vital signs and routine data to track patient status.

Narrative charting

Descriptive, story-like documentation of patient care events.

Admission nursing history form

Initial form at admission capturing demographics, history, and presenting problems.

Nursing care plan

Integrated plan detailing nursing diagnoses, goals, and interventions.

Discharge summary and plan

Documentation summarizing care, education, medications, and follow-up after discharge.

Informed consent

Voluntary agreement by the patient to treatment after understanding risks and benefits.

Living will

A legal document expressing wishes for future medical treatment.

Durable power of attorney for health care

A legal document appointing someone to make health care decisions if the patient cannot.

Code status

The patient’s resuscitation preference (e.g., DNR).

DNR

Do Not Resuscitate; no CPR is to be performed if cardiac/respiratory arrest occurs.

HIPAA

Health Insurance Portability and Accountability Act; sets privacy and security standards for health information.

PHI

Protected Health Information; data that relates to health status, care, or payment.

NCQA

National Committee for Quality Assurance; sets standards for healthcare quality.

TJC

The Joint Commission; accrediting body establishing patient safety and documentation standards.

CMS

Centers for Medicare & Medicaid Services; oversees reimbursement and regulation.

DRG

Diagnosis-Related Group; a reimbursement classification used for billing/payments.

CPOE

Computerized Provider Order Entry; electronic orders for medications and tests.

CIS

Clinical Information System; supports clinical data management and decision making.

CDSS

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

NCIS

Nursing Clinical Information System; nursing-focused information system.

NCDSS

Nursing Clinical Decision Support System; nursing-specific decision support.

TO

Telephone order; an order received by telephone.

VO

Verbal order; an order given verbally.

TORB

Telephone Order Read Back; read-back verification of TO/VO orders.

Handoff reports

Verbal or written transfer of patient information during shift changes, often using SBAR.

Do Not Use list

TJC-endorsed list of abbreviations to avoid to prevent misinterpretation and ensure safety.

Health care record

The written or electronic account of patient data, clinical interventions, responses, and status used for communication among the health care team.

Electronic Health Record (EHR)

A lifetime computerized record of a patient’s health information that can be accessed across encounters and linked across facilities.

SBAR

A structured communication approach: Situation, Background, Assessment, and Recommendation used during handoffs.

ISBARR

SBAR with Readback; SBAR plus an explicit readback step to confirm understanding.

DAR

Data, Action, Response; a documentation format used in nursing notes.

PIE

Problem, Intervention, Evaluation; a documentation format focusing on problems and actions.

SOAP

Subjective, Objective, Assessment, Plan; a standard format for progress notes.

Flowsheets

Per-shift records of vital signs and routine data to track patient status.

Narrative charting

Descriptive, story-like documentation of patient care events.

Admission nursing history form

Initial form at admission capturing demographics, history, and presenting problems.

Nursing care plan

Integrated plan detailing nursing diagnoses, goals, and interventions.

Discharge summary and plan

Documentation summarizing care, education, medications, and follow-up after discharge.

Informed consent

Voluntary agreement by the patient to treatment after understanding risks and benefits.

Living will

A legal document expressing wishes for future medical treatment.

Durable power of attorney for health care

A legal document appointing someone to make health care decisions if the patient cannot.

Code status

The patient’s resuscitation preference (e.g., DNR).

DNR

Do Not Resuscitate; no CPR is to be performed if cardiac/respiratory arrest occurs.

HIPAA

Health Insurance Portability and Accountability Act; sets privacy and security standards for health information.

PHI

Protected Health Information; data that relates to health status, care, or payment.

NCQA

National Committee for Quality Assurance; sets standards for healthcare quality.

TJC

The Joint Commission; accrediting body establishing patient safety and documentation standards.

CMS

Centers for Medicare & Medicaid Services; oversees reimbursement and regulation.

DRG

Diagnosis-Related Group; a reimbursement classification used for billing/payments.

CPOE

Computerized Provider Order Entry; electronic orders for medications and tests.

CIS

Clinical Information System; supports clinical data management and decision making.

CDSS

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

NCIS

Nursing Clinical Information System; nursing-focused information system.

NCDSS

Nursing Clinical Decision Support System; nursing-specific decision support.

TO

Telephone order; an order received by telephone.

VO

Verbal order; an order given verbally.

TORB

Telephone Order Read Back; read-back verification of TO/VO orders.

Handoff reports

Verbal or written transfer of patient information during shift changes, often using SBAR.

Do Not Use list

TJC-endorsed list of abbreviations to avoid to prevent misinterpretation and ensure safety.

What are the primary purposes of a health care record?

Communication among the health care team, legal documentation, financial billing, education, research, and auditing.

What are the common benefits of using an Electronic Health Record (EHR)?

Improved access to patient information, enhanced data accuracy and legibility, reduced medical errors, streamlined workflow, and better coordination of care.

What is the primary reason for the 'Do Not Use' list?

To reduce the risk of medication errors and miscommunication among health care professionals by eliminating ambiguous or commonly misunderstood abbreviations.

What does 'Advanced Directives' encompass?

Legal documents that allow individuals to make decisions about their medical care in advance, such as a Living Will and a Durable Power of Attorney for health care.

What types of information are considered Protected Health Information (PHI) under HIPAA?

Any information about health status, provision of health care, or payment for health care that can be linked to a specific individual (e.g., patient names, addresses, birth dates, medical record numbers, diagnoses, treatment information).

Health care record

The written or electronic account of patient data, clinical interventions, responses, and status used for communication among the health care team.

Electronic Health Record (EHR)

A lifetime computerized record of a patient’s health information that can be accessed across encounters and linked across facilities.

SBAR

A structured communication approach: Situation, Background, Assessment, and Recommendation used during handoffs.

ISBARR

SBAR with Readback; SBAR plus an explicit readback step to confirm understanding.

DAR

Data, Action, Response; a documentation format used in nursing notes.

PIE

Problem, Intervention, Evaluation; a documentation format focusing on problems and actions.

SOAP

Subjective, Objective, Assessment, Plan; a standard format for progress notes.

Flowsheets

Per-shift records of vital signs and routine data to track patient status.

Narrative charting

Descriptive, story-like documentation of patient care events.

Admission nursing history form

Initial form at admission capturing demographics, history, and presenting problems.

Nursing care plan

Integrated plan detailing nursing diagnoses, goals, and interventions.

Discharge summary and plan

Documentation summarizing care, education, medications, and follow-up after discharge.

Informed consent

Voluntary agreement by the patient to treatment after understanding risks and benefits.

Living will

A legal document expressing wishes for future medical treatment.

Durable power of attorney for health care

A legal document appointing someone to make health care decisions if the patient cannot.

Code status

The patient’s resuscitation preference (e.g., DNR).

DNR

Do Not Resuscitate; no CPR is to be performed if cardiac/respiratory arrest occurs.

HIPAA

Health Insurance Portability and Accountability Act; sets privacy and security standards for health information.

PHI

Protected Health Information; data that relates to health status, care, or payment.

NCQA

National Committee for Quality Assurance; sets standards for healthcare quality.

TJC

The Joint Commission; accrediting body establishing patient safety and documentation standards.

CMS

Centers for Medicare & Medicaid Services; oversees reimbursement and regulation.

DRG

Diagnosis-Related Group; a reimbursement classification used for billing/payments.

CPOE

Computerized Provider Order Entry; electronic orders for medications and tests.

CIS

Clinical Information System; supports clinical data management and decision making.

CDSS

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

NCIS

Nursing Clinical Information System; nursing-focused information system.

NCDSS

Nursing Clinical Decision Support System; nursing-specific decision support.

TO

Telephone order; an order received by telephone.