Fond. Unit 2, Study Guide (2)

Vocabulary key terms and definitions based on Foundations of Nursing Unit 2, covering documentation standards, SBARR, nursing process roles, assessment types, transfers, and discharge planning.

FACT

A documentation standard requiring entries to be Factual, Accurate, Complete, and Timely.

Paper-Chart Error Correction

The procedure of drawing one line through an entry so it remains readable, labeling it "error," initialing, dating/timing it, and entering the correct information.

Late Entry

Documentation added for a forgotten entry, labeled as "Late Entry," stating when the event actually occurred, and signed and dated by the nurse.

Incident Report

A record completed for an unexpected event such as a fall, medication error, or needlestick, which is maintained outside the patient's medical record.

SBARR

A structured communication model used when reporting patient changes or handing off care, standing for Situation, Background, Assessment, Recommendation, and Read back.

Situation (SBARR)

The component of SBARR communication that identifies the current patient concern.

Background (SBARR)

The component of SBARR communication detailing the patient's relevant medical history.

Assessment (SBARR)

The component of SBARR communication presenting current clinical findings.

Recommendation (SBARR)

The component of SBARR communication stating the requested action or intervention.

Read back (SBARR)

The final step in SBARR communication used to confirm transmitted information or medical orders.

Charting by Exception

A documentation method where, after a required baseline assessment, only findings or changes outside expected standards are charted.

Focused Assessment

An assessment addressing a specific problem, used especially when a patient is critically ill, disoriented, or unable to respond.

Subjective Data

Health information reported directly by the patient, such as a self-reported pain score.

Objective Data

Health information that is directly observed or measured by the clinician, such as blood pressure.

Primary Data Source

The patient, who serves as the primary origin of health information.

Secondary Data Sources

Sources of clinical information other than the patient, including family, caregivers, medical records, and other clinicians.

SMART Goals

Patient-centered outcome goals that are Specific, Measurable, Attainable, Relevant, and Time-oriented.

Implementation

The nursing process step of performing planned interventions and documenting the care provided.

Evaluation

The nursing process step that determines whether interventions worked by assessing if patient goals are met, unmet, or continuing.

Intraagency Transfer

A patient movement occurring within the same facility, such as moving from the emergency department to a medical unit.

Interagency Transfer

A patient movement occurring between different facilities, such as from a hospital to long-term care.

Discharge Planning

The process of preparing a patient for transition out of the facility, which begins upon admission.