| A | B |
|---|
| auditors | people appointed to examine patient charts and health records to assess the quality of care |
| chart (health care record) | legal record that is used to meet many demands of the health accreditation, medical insurance, and legal systems. |
| charting | process of recording information on a patient's chart |
| charting by exception (BCE) | recording only new data or changes in patient status or care; charting the exceptions to the previously recorded data |
| database | large store or bank of information, as in forming the patient's nursing diagnosis |
| diagnosis-related groups (DRGs) | system that classifies patients by age, diagnoses, and surgical categories; used to predict the use of hospital resources, including the length of stay |
| documenting | process of adding information to the chart, usually at prescribed intervals |
| Kardex (or Rand) | a card system used to consolidate patient orders and care needs in a centralized, concise way |
| narrative charting | traditional system of charting in which the nurse documents in story form all pertinent patient observations, care, and responses in the nurse's notes section of the patient's records |
| nomenclature | a classified system of technical or scientific names and terminology |
| nursing care plan | plan of care based on a nursing assessment and a nursing diagnosis; lists nursing actions necessary to meet a patient's needs |
| nursing notes | the form on the patient's chart on which nurses record their observations, care given, and the patient's response |
| peer review | an apraisal by professional co-workers (of equal status) or the way an individual nurse conducts practice, education, or research |
| problem list | prioritized master list of the patient's active, inactive, temporary, and at-risk medical or other problems; serves as an index tot he rest of the record |
| problem-oriented medical record (POMR) | method of recording data about the health status of a patient in a problem-solving system. Parts included are the database, problem list, initial plan, and progress notes |
| quality assurance, assessment, improvement | in health care, any evaluation of services provided and the results achieved as compared with accepted standards |
| recording | process of adding written information to the chart, usually at prescribed intervals |
| SOAPE | charting format used in POMR. Components include subjective data (s), objective data (o), assessment (a), plan (p), evaluation (e) |
| SOAPIER | same as SOAPE charting except that intervention (i) and revision (R) are added. |
| traditional (block) chart | conventional patient chart broken down into sections or blocks; included are admission data, physician's orders, history and physical examination,nursing care plan, nurses' notes and graphics, progress notes, and test data |
