Standards and Guidelines
The Parts that Make the Whole
Improving Patient Care
General Terminology
100
This is commonly known as NIC.
What is a Nursing Interventions Classification?
100
A piece of work to be done or undertaken that can be assigned to a person or group of people.
What is a task?
100
A set of questions and answers used to determine a score or gather information. The information collected may be both subjective and objective.
What is an assessment?
100
These are a list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution.
What are problem lists?
200
This is commonly known as NOC.
What is Nursing Outcomes Classification?
200
These are clinical risk categorizations of a patient condition to provide more accurate measurement of future risk and more relevant description of the key factors underlying risk.
What are risk scores?
200
The practice of health care in which the practitioner systematically finds, appraises, and uses the most current and valid research findings as the basis for clinical decisions.
What is evidence based practice?
200
These are conditions experienced by the patient or the patient's family for which the nurse may provide professional service.
What are nursing problems?
300
The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services.
What is care coordination?
300
The codification of Standards of Care to create a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course.
What are care pathways?
300
This outlines the personalized care to be provided to a patient based on care pathways relevant to the conditions, wellbeing, and current health of the patient.
What is a care plan?
300
These are omissions of expected care or result.
What are gaps in care?
400
These are written statements describing the rules, actions, or conditions that direct patient care.
What are standards of care?
400
These are professionals who coordinate care for a panel of patients throughout the continuum of care to ensure that care is timely, appropriate, of high quality and cost effective.
What are care coordinators?
400
Standardized information provided by a care team member with regard to a specific condition, intervention or goal.
What is patient education?
400
These guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.
What are Clinical Practice Guidelines?
500
These are the components that make up a "SMART" goal.
What is Specific, Measurable, Attainable, Realistic, and Timed?
500
These are specific actions such as assisting patients with performing their ADLs or seeing to their safety and comfort that a nurse can prescribe or order.
What are nursing interventions?
500
It is "Using dynamic inputs to create an interactive, holistic, and ever evolving plan that is individualized to each patient with the goal of assisting the care team in collaboration with the patient to achieve the best possible health for their specific circumstance."
What is the Optum Care Suite Vision?
500
This is an object or situation that can cause symptoms to appear or worsen.
What is a trigger?