Nur 231 Chapter 19- Documenting and
Reporting Questions and Correct
Answers
Bedside report ✅standardized, streamlined shift report system at the bedside; helps
ensure the safe handoff of care between nurses by involving the patient and family
Change of shift report ✅communication method used by nurses who are completing
care for a patient to transmit patient information to nurses who are about to assume
responsibility for continuing care; may be exchanged verbally in a meeting or
audiotaped
Charting by exception (cbe) ✅shorthand method for documenting patient data that are
based on well-defined standards of practice; only exceptions to these standards are
documented in narrative notes
Confer ✅to consult with someone to exchange ideas or to seek information, advice, or
instructions
Consultation ✅process in which two or more individuals with varying degrees of
experience and expertise deliberate about a problem and its solution
Critical/collaborative pathway ✅case management plan that is a detailed, standardized
plan of care developed for a patient population with a designated diagnosis or
procedure; it includes expected outcomes, a list of interventions to be performed, and
the sequence and timing of those interventions
Discharge summary ✅description of where the patient stands in relation to problems
identified in the record at discharge; documents any special teaching or counseling the
patient received, including referrals
Documentation ✅written, legal record of all pertinent interventions with the patient—
assessments, diagnoses, plans, interventions, and evaluations
Electronic health record (ehr) ✅digital version of a patient's chart that may contain the
patient's medical history, diagnoses, medications, treatment plans, immunization dates,
allergies, radiology images, and laboratory and test results
Flow sheet ✅graphic record of abbreviated aspects of the patient's condition (e.g., vital
signs, routine aspects of care)
, Focus charting ✅a documentation system that replaces the problem list with a focus
column that incorporates many aspects of a patient and patient care; the focus may be
a patient strength or a problem or need; the narrative portion of focus charting uses the
data (d), action (a), response (r) format
Graphic record ✅form used to record specific patient variables
Handoff ✅a nurse's report to another nurse or health care provider about a patient's
status and progress
Health information exchange (hie) ✅an electronic system that allows physicians,
nurses, pharmacists, other health care providers, and patients to appropriately access
and securely share a patient's vital medical information
-timely sharing of vital patient information can better inform decision making at the point
of care and allow providers to avoid readmission and medication errors, improve
diagnoses, and decrease duplicate testing
Incident report ✅a report of any event that is not consistent with the routine operation
of the health care facility that results in or has the potential to result in harm to a patient,
employee, or visitor
Isbar communication ✅a process for effective handoff communication among health
care professionals about a patient's condition, standing for identity/introduction,
situation, background, assessment, recommendation, and read back
Minimum data set ✅a standard established by health care institutions that specifies the
information that must be collected from every patient
Narrative notes ✅progress notes written by nurses in a source-oriented record
Occurrence charting/variance charting ✅documentation when a patient fails to meet an
expected outcome or a planned intervention is not implemented, including the
unexpected event, the cause of the event, actions taken in response to the event, and
discharge planning, when appropriate; typically used for variances that affect quality,
cost, or length of stay
Outcome and assessment information set (oasis) ✅assessment instrument
representing core items of a comprehensive assessment for adult nonmaternity home
health care patients that forms the basis for measuring patient outcomes for the
purpose of improving the quality of care provided
Patient record ✅a compilation of a patient's health information; the patient record is the
only permanent legal document that details the nurse's interactions with the patient
