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What is the process called when records are reviewed?
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Audit
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Skills that include problem solving, decision making, thinking and creativity
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Cognitive skill
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Review of a client's health care while the client is still receiving care
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Concurrent audit
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Consists of two parts: a conclusion and supporting data
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Evaluation statement
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Focuses on how care was given
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Process evaluation
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A program that is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients.
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Quality assurance program (QA)
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Ongoing, systematic approach with the focuse on improving the quality of care
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Quality improvement (QI)
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Evaluation of a client's record after discharge from an agency
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Retrospective audit
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Process for identifying the factors that bring about deviations in practices that lead to a sentinel event
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Root cause analysis
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Unexpected event that involves death or serious physical or psychological injury or risk thereof
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Sentinel event
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An evaluation that focuses on the setting in which the care was given
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Structural evaluation
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Purposeful hands on skills
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Technical skills
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Planned ongoing activity in which the client and health care professionals determine the client's progress toward achievement of goals and effectiveness of nursing care plan
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Evaluating
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Consist of doing and documenting the activities that are specific nursing actions to carry out interventions
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Implementing
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All of the activities, verbal, and nonverbal, people use when interacting directly with one another
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Interpersonal skills
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