Part of diagnostic reasoning. The process of drawing conclusions from related pieces of evidence and
previous experience with evidence - Clinical inference
Classifications based on a patients primary and secondary medical diagnosis that are used as the basis
for establishing Medicare reimburseme...
Part of diagnostic reasoning. The process of drawing conclusions from related pieces of evidence and
previous experience with evidence - Clinical inference
Classifications based on a patients primary and secondary medical diagnosis that are used as the basis
for establishing Medicare reimbursement for patient care. - Diagnosis-related groups (DRGs)
A combination of hardware and software that protects private network resources - Firewall
A system of organizing documentation to place primary focus on patients individual problems -
Problem-oriented medical record (POMR)
Address the patient concerns: A sign or symptom, condition, nursing diagnosis, behavior, and change in
patients condition - DAR notes (Data, Action, Response)
Chart methodology in which data are entered only when there is an exception from that which is normal
or expected; reduces time spent documenting in charting. Shorthand method for documenting normal
findings and routine care - Charting by exception (CBE)
Inter professional care plans that identify patient problems, key interventions, and expected outcomes
within an established time frame - Critical Pathways
Unexpected event that occurs during patient care and that is different from CareMao predictions.
Interventions or outcomes that are not achieved as anticipated. May be positive or negative -
Variances
Documents on which frequent observations or specific measurements are recorded. - Flow sheets
, Written care plans used for groups of patients who have similar health care problems. -
Standardized care plans or Clinical practice guidelines
Mechanism by which entries describing patient care activities are made over a 24 hour period. The
activities are then translated into a rating score that allows for comparison of patients who vary by
severity of illness - Acuity recording
Comprehensive computerized system used by all healthcare practitioners to permanently store
information pertaining to a patients health status, clinical problems, and functional abilities -
Computer-based patient record
A confidential document that describes any patient accident while the person is on the premises of a
health care agency. - incident report
management and processing of information, generally with the assistance of computers -
Information technology (IT)
the application of computer and information science in all basic and biomedical sciences to facilitate the
acquisition, processing, interpretation, optimal use, and communication of health related data -
Health informatics
Use of information and computer technology to support all aspects of nursing practice, including direct
delivery of care, administration, education, and research. - Nursing informatics
A computer based system that collects, stores, and manipulates, data to allow health care providers to
make informed decisions about patient care. - Clinical information system
A system that incorporates the principles of nursing informatics to support the work that nurses do by
facilitating documentation of nursing process activities and offering resources for managing nursing care
delivery.
Allows the nurse to share the care plan immediately with the patient.
Can check on Laboratory results. - Nursing Clinical Information system (NCIS)
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