Reporting 1
the S in SBAR stands for
what is situation
the A in SBAR stands for
what is assessment
the R in SBAR stands for
what is recommendation
Data arranged according to patient problems rather than source of information
what is problem oriented medical record
eMARs stands for
what is the electronic medication administration record
one opportunity for use of handoff communication
transfer between units
when receiving a telephone order from a provider, the nurse should always _____ before hanging up
___ regulations maintain privacy, confidentiality of protected health
information
what is HIPAA
Chart entry made by any healthcare professional involved in the patient’s
care
what is a progress note
EHR stands for
what is electronic health record
Verbal or written transfer of information, authority, responsibility during transitions of
care
what is handoff communication
VO stands for
what is verbal order
the B in SBAR stands for
what is background
– Subjective data
– Objective data
– Assessment
– Plan of care
– Interventions
– Evaluation
– Revision
what is the SOAPIER note format
Dx
what is the medical abbreviation for diagnosis
TO stands for
what is a telephone order
a second opportunity for use of handoff communication
at change of shift
a documentation system in which only abnormal or significant findings or exceptions to norms are recorded
what is charting by exception
▪ Initial list made with reference to active problems
▪ Generated by individual who lists the problems
▪ Written plan listed under each problem in progress notes, not isolated as
separate list of orders
what is plan of care
the joint commission requires that the clinical record include evidence of pt assessments, nursing diagnoses, and/or pt needs, nursing interventions, outcomes- what is this??
what is a nursing care plan
• Purpose: to provide continuity of care for patients by providing new caregivers with
quick summary of patient needs, details of care to be given
• May be written or oral, face to face or audio recording
• May be given at bedside
• Patients may participate in exchange
what is change of shift report
nurses should never follow what type of order
what is a voice mail order
Allows for collaborative reporting among healthcare professionals caring for patient
• Most often for patients with complex care needs
• Providers discuss possible solutions to patient’s problems
• Gives each member of team opportunity to offer opinion
– Other professionals may be invited
what is a care plan conference
Also referred to as an initial database, nursing history, or nursing assessment
• Completed when patient is admitted to nursing unit
what is the admission nursing assessment
if it wasn't charted, it wasn't ___
done!!