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admission sheet
the initial record filled out when a patient is admitted to a healthcare facility
case management model
a comprehensive form of documentation that involves coordinating and tracking patient care across different stages and settings
charting by exception
the practice of documenting only significant findings or exceptions to norms
clinical knowledge
a nurse’s understanding of health and disease processes, treatments, and interventions
cognitive skills
the mental processes involved in understanding patient needs, planning care, problem-solving, and decision-making
cultural sensitivity
awareness and respect of a patient’s cultural background and beliefs
dependent intervention
an action that a nurse carries out under the orders or direction of a healthcare provider, such as a physician
direct care
interventions that involve personal contact or interaction with patients
Donabedian model
a framework used in healthcare quality assessment and improvement that organizes the elements necessary for evaluating healthcare quality into three main categories: structure, process, and outcomes
evaluation
the systematic determination of a patient’s progress toward the achievement of outcomes and goals set during the care-planning process
flow sheet
a brief form that contains the most important information about a patient; it travels in their chart
focused charting
the practice of documenting care and observations based on specific patient concerns or behaviors
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
a standardized survey instrument and data collection methodology for measuring patients’ perspectives on hospital care throughout the United States
implementation
the step of the nursing process when the plan of care for a patient is put into action
independent intervention
an action that a nurse initiates and carries out based on their own clinical judgment, without instructions from others
indirect care
interventions that are performed away from patients but are vital to their overall care
interdependent intervention
an action that requires the nurse to coordinate with other providers as part of a care team
interpersonal skills
the abilities that enable effective communication and interaction with patients, their families, and other healthcare professionals
intervention
an action intended to stop a harmful outcome or promote a healthful one
narrative notes
documentation written in paragraph form to better “tell the story” of a patient’s health
National Database of Nursing Quality Indicators (NDNQI)
a comprehensive repository of data relevant to nursing-sensitive quality indicators in the United States
nursing-sensitive quality indicators
specific metrics that are influenced by nursing behaviors and that reflect the quality of nursing care
outcome evaluation
an assessment of the results of health care on patients and populations
PIE method
a form of problem-oriented documentation consisting of Problem, Intervention, and Evaluation data
problem-oriented documentation
a method of recording patient care that focuses on the patient’s specific health problems rather than the source of data
process evaluation
an assessment of how a healthcare system or provider delivers care
psychomotor skills
the practical, hands-on abilities required to effectively implement interventions
quality assurance (QA)
oversight to ensure that current quality standards are being met across a department or agency and that staff are receiving the education and infrastructure support to maintain that quality
quality health care
the provision of health services that improve the chances of preferred outcomes, decrease the chances for error, and are consistent with current evidence and knowledge
quality improvement (QI)
a framework to improve patient care and outcomes systematically
SOAP method
a form of problem-oriented documentation consisting of Subjective, Objective, Assessment, and Plan data
source-oriented documentation
a traditional method of recording healthcare information, in which data is organized based on the person providing it
structure evaluation
an assessment of the characteristics of a healthcare system or provider
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