| 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 storm all pertinent patient observations, care, and responses in the nurse's notes section of the patient's records |
| nomenclature | a classified systm of technical or scientific names and terminology |
| nursing care plan | Plan of care based on a nursing assessment and a nursing diagnosis; list 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 responses |
| peer review | An appraisal 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, in-active, temporary, and at-risk medical or other problems; serves as an index to the 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, and 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) reported by the patient; objective data (O) acquired by inspection, percussion, auscultation, and palpation and by tests, usually measurable findings; assessment (A) of the problem; plan (P) of care; and evaluation (E) of the patient's response to the treatment plan. |
| SOAPIER | Same as SOAPE charting except that intervention (I) and revision (R) are added. Interventions are specific actions carried out, and revisions are the changes to be made to the original plan |
| 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 |
