- advance directive
- legal document that lists the patient’s wishes regarding life-sustaining medical treatments
- age of majority
- defined by each U.S. state as the age at which one can make their own decisions, including health-care decisions
- alternative substance
- nonregulated herbal substance or homeopathic medication
- chief complaint
- statement of the signs and symptoms that have led the patient to seek medical attention
- collaborative problem
- a certain physiological response the nurse monitors that can be addressed through nursing intervention and physician-prescribed treatments
- demographic data
- identifying basic patient information
- electronic health record (EHR)
- digital format of a patient’s chart that contains data related to the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
- electronic medical record (EMR)
- single facility’s digital version of a patient’s chart
- familial disease
- disease that tends to occur often in particular families
- health information exchange (HIE)
- vehicle for doctors, nurses, patients, and other interdisciplinary healthcare members to access and securely share critical healthcare information electronically, improving the speed, quality, safety, and cost of patient care
- Health Information Technology for Economic and Clinical Health (HITECH) Act
- a law that promotes meaningful ways to incorporate health information technology while still protecting patients’ privacy rights
- Health Insurance Portability and Accountability Act(HIPAA)
- law that details national standards for electronic healthcare transactions and protection of privacy for health information
- health record
- collection of subjective and clinical information pertaining to a patient’s physical and mental health, compiled from a variety of sources
- healthcare informatics
- field that incorporates health care and computer and information sciences
- hereditary disease
- disease passed down from generation to generation
- initial health assessment
- systematic and purposeful collection and analysis of patient information
- interoperability
- the ability to share patient information across multiple healthcare systems in digital format
- meaningful use
- using electronic health information in a meaningful way to improve patient care
- medical power of attorney
- legal document that outlines who can make medical decisions on behalf of the patient in the event they cannot do so themselves
- minimum data set (MDS)
- standard established by healthcare institutions that specifies the information that must be collected from every patient
- nursing diagnosis
- clinical judgment based on the medical diagnosis of a patient that helps the nurse determine the plan of care
- objective data (also, signs)
- information observed through your senses of hearing, sight, smell, and touch while assessing the patient
- over-the-counter medication
- medication that does not require a prescription
- Patient Care Partnership
- document that tells the patient what to expect while receiving medical care under the organization and outlines their rights; formerly called a Patient Bill of Rights
- physical finding
- the assessment of a body system
- primary source
- the patient
- secondary source
- information obtained from the history section of the health record, or the patient’s family
- signs (also, objective data)
- information observed through your senses of hearing, sight, smell, and touch while assessing the patient
- subjective data (also, symptom)
- information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance
- subpoena duces tecum
- court order to produce documents or records
- symptom (also, subjective data)
- information obtained from the patient and/or family members and can provide important cues about functioning and unmet needs requiring assistance
- treatment plan
- used to increase patient outcomes related to a specific disease or condition
- usability
- extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use
- vital sign
- a marker of physiological homeostasis and essential in the analysis of monitoring patient progress; obtained by measuring body temperature, pulse, respiratory rate, and blood pressure