Key Terms

auditors
chart (health care record)
charting 
charting by exception
computer on wheels
database (DĀ-tă-bās)
diagnosis-related groups
documenting 
electronic health record
electronic medical record
informatics
Kardex (or Rand)
narrative charting
nomenclature (NŌ-mĕn-klā-chŭr)
nursing care plan
nursing notes

peer review 

personal health record
point-of-care
problem list 
problem-oriented medical record
quality assurance, assessment, and improvement
recording 
SBAR 
SOAPE (SŌP)
SOAPIER (SŌP-ē-ŭr)
traditional (block) chart