Terminology Definition

Accountability Evidence-based quality indicators focus on client care and the

measures improvement of the outcomes of care. Developed by The Joint
Commission and Centers for Medicare and Medicaid Services.
Case management Providing high-quality care while effectively using healthcare
resources and controlling costs.
Change-of-shift A means of exchanging information between outgoing and incoming
reporting staff on each shift.
Charting by exception Type of narrative charting that usually uses a flow sheet listing the
body systems and their typical findings, such as lung sounds: clear,
crackles, or rhonchi. The nurse checks the correct finding in the
preprinted box.
Core measures Reclassified as accountability measures, they are sets of actions
based on the evidence-based quality of care and the best possible
outcomes.
Discipline area Documentation style that includes a separate note for healthcare
(multidisciplinary) providers, nurses, and other healthcare team members, such as
documentation dietary, respiratory therapy, physical therapy, occupational therapy,
or home health providers.
Electronic medical Rapid documentation in healthcare facilities uses various,
records individualized, computerized formats.
Evidence-based The collection and correlation of scientific research studies, clinical
practice studies, clinical expertise, and client perspective. Nursing research
integrates scientific evidence with clinical and client data to achieve
high-quality outcomes that formulate nursing interactions or nursing
protocols.
Focus charting Charting that focuses on specific problems, for example, a client
reports a headache charting will focus on documentation of pain.
Graphic flow sheet Graph, form, or picture that records a large amount of information
collected at intervals over specified periods in brief, concise entries.
Medication A document that lists all medications that a healthcare provider
administration record orders for a client with spaces for marking when medications are
given
Narrative charting Type of nurses’ notes that essentially documents what is occurring
throughout the day in a chronological manner.
Nurses’ notes Type of nurses’ notes that essentially documents what is occurring
throughout the day in a chronological manner.
Problem-oriented A type of charting focused on specific problems; is sometimes called
medical records focus charting. Used to support collaborative healthcare teams in
identifying and solving priority problems.
Progress notes Form nurses fill out at regular intervals to summarize a client’s
condition or response to treatment.
Walking rounds Caregivers move from client to client, discussing pertinent
information