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12.1.1 Glossary

The following definitions of key terms are used throughout this chapter :

12.1.1.1 Goal

A goal refers to an objective to be achieved as a consequence of health care interventions applied to an individual. Goals are set in many areas of the health care system, and include educational, behavior modification, and clinical goals such as reduced discomfort, improved circulation. Goals are documented by a variety of health care professionals including physicians, nurses, and respiratory and other therapists. Goals are defined during patient visits and they may span one or multiple visits, encounters, or episodes of care.

12.1.1.2 Problem

A problem of a given individual can be described by formal diagnosis coding systems (such as DRG’s, NANDA Nursing Diagnosis, ICD9, DSM, etc.) or by other professional descriptions of health care issues affecting an individual. Problems can be short or long term in nature, chronic or acute, and have a status. In a longitudinal record, all problems may be of importance in the overall long term care of an individual, and may undergo changes in status repeatedly. Problems are identified during patient visits, and may span multiple visits, encounters, or episodes of care.

12.1.1.3 Role

A role refers to the function or responsibility assumed by a person in the context of a health care event. Role information documents a person’s association with an identified healthcare activity. Examples include primary care provider, transcriptionist, reviewer, and consulting physician.

12.1.1.4 Clinical pathway

A clinical pathway is a standardized plan of care against which progress towards health is measured. A clinical pathway is applied based upon the results of a patient assessment. A clinical pathway shows exact timing of all key patient care activities intended to achieve expected standard outcomes within designated time frames. A clinical pathway includes documentation of problems, expected outcomes/goals, and clinical interventions/orders.

12.1.1.5 Variance

Variances are documented deviations, either positive or negative from a pre-defined standard. Variances are documented against expected outcomes, orders, or the patient’s progress in general.

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