- 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