computerized or paper medical record containing
information such as medical orders, assessments, and care; nursing documentation of plan of care, assessment, and interventions; and diagnostic/surgery results
Chart
healthcare that is provided to people who live within a defined geographic region or who have common needs; designed to meet the needs of people as they move between and among healthcare settings
Community-based Care
coordination of services provided to patients before they enter a healthcare setting, during the time they are in a setting, and after they leave the setting
Continuity of Care
systematic process of preparing the patient to leave the healthcare facility and for maintaining continuity of care
Discharge Planning
federal law enacted to ensure that health information is protected while allowing the flow of health information needed to provide and promote high-quality healthcare and to protect the public’s health and well being
HIPAA Privacy Rule
trade name for the care plan documentation system
that encompasses
1. Prescriptions for nursing care related to
activities of daily living
2. Nursing diagnoses and related patient goals
and nursing orders
3. The nursing care related to diagnostic
measures and the medical regimen