Documentation Standards
The ANA's model for high-quality nursing documentation reflects the ________ _________ and includes accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and retrievability.
What is The nursing process?
A longitudinal record of health that includes the information from inpatient and outpatient episodes of health care.
What is electronic health record?
Mistaken for the number 0 or 4 or for cc
What is U or u?
The use of the Internet to link medical experts with other clinicians, allowing remote consultations with clear video images and high fidelity links.
What is telehealth or telemedicine?
The unique ability of a patient to understand and integrate health-related knowledge.
What is health literacy?
A document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data.
What is the medical record?
In most facilities, the only circumstance in which orders may be issued verbally is in a _____ _______. (2 words)
Medical emergency
Mistaken for IV or the number 10.
What is IU or international unit?
A broad academic field encompassing artificial intelligence, cognitive science, computer science, information science, and social science.
What is informatics?
Effective _________ _________ is key to health promotion and wellness.
What is patient education?
The patient______ is the only permanent legal document that details the nurse’s interactions with the patient.
Record
Adoption of an EHR system produces major _______ ________ through gains in productivity and error reduction.
What is cost savings?
Use instead daily, every other day.
What is QD or QOD?
______ ______ comprises the accumulation of health care--related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom.
Big data
__________ is imparting knowledge or giving instruction, whereas _____________ is acquiring knowledge or skills through instruction or experience.
What is teaching and learning?
Telecare
Knowledge of computers and the ability to use them efficiently.
What is computer literacy?
Nurses need to provide patients with easy-to-understand information and speak in a clear, distinct voice, using short sentences and understandable ______________.
What is terminology?
Every note in the medical record must contain a _____, ______, and ___________.
What is date, time and signature?
10% of Medicare reimbursement
What is the penalty for not having an EMR?
A ________ ___________ is a web-based tool that can be securely accessed and provides several functions to increase engagement.
Patient portal
Critical pathways
Nursing diagnoses specifically related to patient education include: ___________________, _____________________________, and_______________.
What is Deficient Knowledge, Readiness for Enhanced Knowledge, and Noncompliance.