UNIT III: Person-Centered Care and the Nursing Process Chapter 16: Documenting, Reporting, Conferring and Using Infotmatics Vocabulary
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3 methods of communication central to the nurse's professional role:
HIPAA
Write a progress note for each of these instances
Under HIPAA, patients have a right to
read back
the RN who receives the order will
the physician who issed the VO
EHR
EMR
PHR
two types of PHR
Standalone PHR
Tethered/Connected PHR
HIE
source oriented records
progress notes
narrative notes
POMR
SOAP format
PIE charting
focus charting
DAR
CBE
collaborative pathways (critical pathways)
occurrence/variance charting
flow sheets
graphic record
acuity records
OASIS
RAI
RAI consists of 4 basic components
ISBAR communication
ISBAR
ISBAR: I
ISBAR: S
ISBAR: B
ISBAR: A
ISBAR: R
ISBARR
incident/variance report
nursing care rounds
