Accountability A principle of professional practice.  It is being responsible for your own actions and decisions made in the process of providing nursing care.
Australian Commission on Safety and Quality in Health Care (ACSQHC) An organisation that works to attain a safe and reliable health system of high standards.  ACSQHC works with patients, consumers, clinicians, managers, policymakers and healthcare organisations to achieve these standards.
Australian Health Practitioner Regulation Agency (AHPRA) An organisation that protects the public by regulating Australia’s health practitioners in partnership with national boards (for example NMBA).
Chart A person’s medical record.  It is a legal document that records evidence of the care provided to a person.
Charting The act of entering information into the person’s medical record.
Charting by exception (CBE) A system of documenting only the important and new aspects of the person’s status and care.  Norms are not included in the notes.
Clinical governance The systems used by a healthcare facility to enable clinicians and managers to monitor and remain accountable for the safety, effectiveness and quality care of people (for example, charting and incident reporting, contributing to a multidisciplinary team to ensure that patients receive comprehensive care through effective communication).
Clinical pathways Also known as standard care plans, provide a standardised plan that outlines the nursing care required for a person with a specific diagnosis (acute coronary syndrome).
Communication An exchange of information or ideas through speaking, writing or other forms (such as signs).
Confidentiality A set of rules whereby law any information a person provides to their healthcare team will be kept private unless the person provides consent for disclosure to others.
DAE Is similar to DAR, however, evaluation (E) replaces response in this framework.
DAR Is a form of focus charting.  The focus is the nursing diagnosis, data (D) is collected from the person (subjective and objective), actions (A) are implemented based on the person’s condition, and the response (R) to the actions are evaluated for efficacy.
Duty of care Is the responsibility to prevent harm, by avoiding acts or omissions that could be reasonably foreseen to harm other people.  Healthcare professionals must anticipate risks for the people in their care and prevent harm from happening.
Electronic health record (EHR) A digital version of a person’s medical history, that is maintained by the healthcare professional over time. It allows healthcare professionals to simultaneously access and update patient information,  It can include all the key clinical data relevant to the persons care, including demographics, progress notes, problems, medications, vital signs, past medical/surgical l history, immunisations, laboratory results and radiology reports.  An example of an EHR is iEMR (integrated electronic medical record) used by Queensland Health which has such features as the vital signs being automatically uploaded to the persons’ record, triggering early warning alerts if that person’s condition deteriorates.
Incident reports As part of risk management and reporting facilities will have a system for documenting actual or potential injuries, incidents and accidents in the workplace.
Information technology  This includes all digital technologies that support the electronic capture, storage, processing, and exchange of information used to promote health, prevent illness, treat disease, manage chronic illness.  It includes systems such as telehealth. EHR, AusLab, EDIS, and other health digital platforms.
Integrated medical record A chronological record of the person’s care, on an integrated system used by all healthcare professionals for that individual.
ISBAR A structure for providing and efficient and effective verbal handover (for example at shift change, or to escalate the care of a deteriorating patient).
My Health Record (MHR) An online summary of your key health information that can be viewed securely by individuals and their health professionals across Australia.
Narrative documentation A diary or story format (sentence structure)  in chronological order. It is used to document the patient’s status, care, events, treatments, interventions, and the patient’s response to the interventions.
National Safety and Quality Health Service (NSQHS) Standards Aset of national standards to protect the public from harm and to improve the quality of health service provision.
Nursing informatics Integrates information and communication technologies into nursing knowledge and data to promote the health of people, families, and communities.
Nursing and Midwifery Board of Australia (NMBA) In conjunction with AHPRA is responsible for setting standards and policies that all registered health practitioners must meet (for example, professional registration, professional codes, standards and competency issues for all nursing and midwifery registrations in Australia).
Nursing process A systematic method of planning and implementation of nursing care.
Objective data Information that can be observed or tested.  It can be seen, heard, smelled or felt, such as palpating a pulse or auscultating a blood pressure.
Person-centred care (PCC) Places the person at the centre of the nurse’s focus. The nursing care provided meets the individual needs and concerns of the person, leading to improved quality and safety of care provided and better outcomes for the person.
PIE Is part of the nursing decision-making process.  A problem (P) is formulated based on the data collected, interventions (I) are put into place, followed by an evaluation (E) of the effectiveness (or ineffectiveness) of the interventions.
Policy A set of rules to outline the appropriate management of a situation that occurs frequently.
Privacy The legal right that ensures your personal information is kept private.
Problem-orientated (or problem-focused) documentation Information is recorded according to the person’s identified problems.
Progress notes Entries that are made into the person’s medical record (chart) by all health professionals who are involved in the person’s care.  These entries are used to record the person’s problems, treatment and progress to ensure continuity of care.
Quality improvement Activities undertaken by the facility to ensure that organisational processes are continually improved to meet consumer needs.
Recording The action of writing entries into a person’s individual medical record.
Report Conveying information to other health professionals about a person.  It may be oral, written or electronic.
Right A legal term that describes a person’s entitlement (the right to privacy).
SOAP A form of narrative documentation.  It provides a structure for the nurse to follow to guide the inclusion of subjective data from the person (S), objective data about the person (O), assessment of the person (A) and the plan of care (P).
Source-orientated record Is used by a specific department to make a notation in a specific area of a person’s chart structured data elements.  Refer to built-in templates or structures that guide the type of data to be entered in a specific field.
Subjective data A statement by the person that relays how they are feeling (I feel nauseated and I have pain in my left side).
Unstructured data elements Refers to free-text entry that allows for the open-ended documentation of patient data.



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Documentation in Nursing and Midwifery: Australian edition Copyright © 2022 by Tanya Langtree and Elspeth Wood is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.