Show:
Recording
Records
Communication
Admissions etc
Extended Care
100
Private association that has established criteria reflecting high standards for client safety and institutional health care
What is The Joint Commission?
100
It has separate forms on which physicians, nurses, dietitians, and nurses make entries about their own activities in relation to the client's care.
What is a source-oriented record?
100
A written list of the client's problems, goals, and nursing orders for client care.
What is a nursing care plan?
100
This is the result of nonadherence to medication regimens is the reason for more than 10% of older adults.
What is hospital admissions?
100
Provides 24 hour nursing care under the direction of a RN. The client needs daily skilled nursing care like sterile dressing changes or tracheostomy care.
What is a skilled nursing facility?
200
It becomes central to communication. It is a way to inform others about the client's plan of care.
What is a medical record?
200
It contains 4 components: database, problem list, plan of care, and progress notes. The information is arranged and compiled to highlight goal directed care.
What is a problem oriented record?
200
A quick reference that informs others of the client's care and allows caregivers to flip from one client's data to another. it is not part of the client's permanent record.
What is a Kardex?
200
Asking the client's names, date of birth, and checking their bracelet.
What is identifying your patient?
300
Examples: Never criticism of care, never charting for someone else, sign each entry by name and title, and charting promptly after providing care
What is defensible charting?
300
Writing information about a client and their care in chronological order. It is a source oriented type of charting.
What is narrative charting?
300
A way to view and evaluate trends.
What is a flow sheet?
300
Obtaining and verifying the medications a client is currently taking.
What is medication reconciliation?
300
Provides health related care and services to people who because of their mental or physical condition. They require institutional care but not 24 hour nursing care.
What is an intermediate care facility?
400
The Act that allows Clients have a right to see their own medical and biling records and be informed about who has seen their medical chart.
What is HIPAA?
400
Its essential components are: Subjective, Objective, Analysis of data, and Plan for care. Demonstrates interdisciplinary cooperation because everyone involved in care makes entries in same location.
What is SOAP charting?
400
Visits that occur at the bedside of client's on individual basis or as a group and are used to learn firsthand about the client.
What are client rounds or rounds?
400
Termination of care from a health care agency. And this process should begin on admission.
What is discharge?
400
A type of nursing home setting that provides food, shelter, and laundry services.
What is basic care facility?
500
The process for self-improvement to ensure the level of care reflects established standards.
What is quality improvement or quality assurance?
500
Most efficient charting, it is always legible, abbreviations are consistent with approved lists, allows getting quick test results, and multiple health care providers can use the record simultaneously.
What is electronic charting?
500
A model recommended for effective communication. It reviews the situation, background, assessment, and recommendations.
What is SBAR?
500
Discharging a client from one unit or agency and admitting him to another without going home in the interim.
What is a transfer?
500
A process that determines the level of care prior to admission. It is done every 3 months and when a client's condition changes. It assesses cognitive patterns, physical functioning, continence patterns, and oral health, etc.
What is MDS or minimum data set?