Nursing Documentation 101: Glossary of Terms  page 1
Glossary of Terms Active duty – on the job AMA – discharge against medical advice Apps – small software programs used in mobile communication devices Authentication – means true and correct Causal link – trying to prove cause and effect CBE (charting by exception) – is a documentation system that states only significant findings or exceptions to normal findings Cognitive impairment – memory issues Contemporaneously – at the time of occurrence or shortly thereafter Defendants – those being sued or those accused of wrongdoing Disclaimer – a short statement that clarifies your role in the signing procedure Documentation – is sometimes called reporting, charting or recording; can be described as any electronic or written information or data about client interactions or care events that meet both legal and professional standards Encryption – an electronic process that minimizes unauthorized use Hackers – individuals who gain unauthorized access to computer databases Informatics – the merging of medical and nursing science with computer science to better manage health related data
Inputting – entering data into an electronic device Liable – responsible in a legal sense
Glossary

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