Chapter 16: Documenting, Reporting, Conferring and Using Infomatics Vocabulary

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