| Auditors | People appointed to examine patient charts and health records to access quality of care |
| Chart | (Health care record) legal record thats used to meet many demands of health accreditation, medical inc, legal system |
| Charting | Process of recording info on patient chart |
| Recording/ documenting | Process of adding written info to the chart (usually at prescribed intervals |
| Charting by exception | Recording only new data or changes in patients status or care(charting the exceptions to the previously recorded data |
| Computers on wheels (COW) | POC systems housed on wheeled carts |
| Point-of-care (POC) | Computer electric health record systems that are located at the patients bedside |
| Database | Large store bank information, as in forming the patient’s nursing diagnoses |
| Diagnoses-related group | Classifies patients by age,diagnosis, surgical categorías used to predict the use of hospital resources, include hospital stay |
| Electronic health record | An electric patient record designed for health info exchaned between facilities |
| Informatics | Study of information processing |
| ISBAR (Identification, situation ,background, assessment, and recommendation) | A method of communication among health care workers and a part of documentation of communication that has occurred among health care staff. |
| Kardex(rand) | System that is used by some facilities to consolidate patient orders and care needs in a centralized, concise way |
| Narrative charting | Recording of patient care in descriptive form |
| Nomenclature | A classified system of technical or scientific names and terminology |
| Nursing care plan | Outlines the proposed nursing care base on the nursing assessment and the identified patient problems to provide continuity of care |
| Nursing notes | Form on the patients chart on which nurses record their observation, the care given, and the patients responses |
| Patient portal | Online system through a healthcare facility that provides a patient with access to their own health information, corresponding w/ providers logging of appointments, etc |
| Peer review | An appraisal by professional coworkers of equal status |
| Personal health record (PHR) | Extension of the EHR that allows patients to input their info into an electric data base (EHR=Electric health records) |
| Problem list | Prioritized master list of patients active, inactive, temporary and at-risk medical or other problems; serve as an index to the rest of the record |
| Problem-oriented medical record (POMR) | Organized according to the scientific problem-solving system or method |
| Quality assurance, assessment, and improvment | An audit in health care that evaluates services provided and results achived compared with accepted standards |
| SOAPE | Is the briefer adaptation of the charting format for the POMR(problem-oriented medical record) |
| SOAPIER | An acronym for seven different aspects of charting (specific problems, only necessary parts) |
| Traditional(block) chart | Divided into sections/ blocks (specific sections- admissions data, physicians order, history and physical exam etc |
| Electric medical records | Electronic patient record designed for health info exchange only within a facility |
