Appendix B. Definitions

A Toolkit for Redesign in Health Care: Final Report

Staff Observation

TermDefinition
Adjust equipmentAdjusting any type of patient specific equipment such as an IV pump.
AdministrativePerforming administrative or office type duties.
Answer call lightAnswering a call light initiated by a patient or a patient's family member.
Answer telephoneAnswering the telephone.
Answering pageResponding to a page.
Answers alarmAnswering an alarm on patient-specific equipment such as an IV pump or cardiac monitor.
AssessmentAssessing a patient's condition. A provider or a nurse can do this.
Attend to patientAny nonspecific contact with the patient.
Attending classAttending an educational class.
Bathe patientBathing or washing a patient.
Calls for assistanceCalling for assistance to help with a task.
ChartingDocumenting in the patient's medical record.
Charting (flow)Documenting on the patient's bedside flow sheet.
Charting (meds sheet)Documenting on the patient's medication sheet (usually performed by a nurse).
Charting (orders)Writing orders in the patient's medical record.
Charting (progress note)Documenting the patient's progress in the medical record.
Checking for ordersChecking the medical record for new orders.
CleaningCleaning a patient room post-discharge.
Cor-0 or Code blueWorking in a code or Cor situation.
Consult with nurseDiscussing a patient's medical care with a nurse.
Consult with providerDiscussing a patient's medical care with a provider.
Crushing medsCrushing or preparing medications before administration to a patient.
Down timeTime that is not used to benefit the patient, such as eating lunch.
Entering ordersEntering orders into a CPOE (computerized physician order entry) system.
Gives medsAdministering medications to a patient.
Lab drawObtaining a specimen from a patient.
Looking up labsLooking up laboratory results on a computer.
Making copiesMaking photocopies.
Monitors EKGsWatching the unit's central cardiac monitor station.
Obtain vital signsObtaining vital signs on a patient.
Obtains medicationObtaining medication(s) from the pharmacy or a medication distribution system.
Office workAdministrative duties related to the operations of a department.
Pages providerPaging a physician.
PaperworkWorking on nonmedical paper work (e.g., payroll).
Place pagePaging other staff personnel.
Procedure (simple)A nonsurgical procedure usually performed in the patient's room (e.g., patient's catheter).
Procedure (invasive)An invasive procedure not performed in the operating room (usually performed at the bedside (e.g., a central line).
Pyxis med stationAutomated medication-dispensing station.
ReportGiving or receiving report from another person, shift, or unit.
Review med sheetReviewing the patient's medication sheet (usually performed by a nurse).
Review chartReviewing the medical record, checking for new orders, or checking for order accuracy.
RoundsAttending patient care rounds (usually attended by physicians).
SearchingSearching for some item not readily available.
SuppliesObtaining needed supplies.
SurgeryPerforming surgery. This is done in the operating room.
Talk to familySpeaking with a patient's family member.
Technical problemWorking on or fixing some type of technical problem, usually related to computer systems.
Telephone callMaking a telephone call.
TransportMoving a patient from one area of the hospital to another.
TravelMoving from one area of the hospital to another.
Travel linenTraveling to a linen closet to obtain linens.
Travel medicationsTraveling to a medication station or a medication room with the purpose of obtaining medications.
Travel supplyTraveling to a supply station or a supply room with the purpose of obtaining supplies.
WaitingA period of inactivity while waiting.

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Patient Observation

TermDefinition
Adjust equipmentA clinical person makes any type of adjustment to patient-specific equipment such as an IV pump. (An example would be a nurse adjusting the infusion rate on the IV pump.)
Admission processPatient undergoes any part of the admission process, such as an initial history and physical.
Ambulates with nursePatient walks around the unit with the nurse in attendance.
Answer alarmA nurse or other clinician enters the room to attend to an alarm on a piece of medical equipment.
Ask/answer questionsPatient answers or asks questions of a clinical person.
AssessmentClinician assesses the patient's condition (may be part of a history and physical).
Attend to patientAny nonspecific contact with the patient by a clinician.
Baby assessmentAssessment of a newborn by a clinician.
Baby to/from nurseryTransportation of a newborn to or from the nursery.
BathePatient is bathed or washed by a member of the health care team.
Blood drawPatient's blood is taken either by a clinician or lab personnel.
Care questionPatient asks question(s) of a clinician regarding his or her care.
CAT scanPatient undergoes a CAT scan.
Check on patientA clinician looks in on the patient to make sure everything is OK but does not do anything specific or have actual hands-on contact.
Cor-0 or Code blueThe patient is involved in a cor or a code situation.
DischargePatient is discharged from the hospital.
Discharge educationPatient undergoes education before discharge (i.e., education on medications, wound care, etc.).
Discuss carePatient discusses the plan or course of care with a clinician.
EatingPatient is eating.
Equipment placed/checkedA clinician sets up and/or checks medical equipment in the patient's room.
EvaluationEvaluation of the patient's condition by a clinician.
Examine patientHands-on examination of the patient by a clinician.
Feed babyFeeding of the newborn by hospital personnel.
Gets dressedThe patient gets dressed.
Lab drawThe patient has a specimen taken either by a clinician or lab personnel.
Linen changeBed or linen is changed.
LinensLinens are delivered into the patient's room by hospital personnel.
Monitor patientA clinician is at the bedside monitoring the patient but does not have any other contact with the patient.(Often the patient is unaware of this act.)
No patient activityNo activity from the patient. (The patient may be resting or sleeping during this time.)
PaperworkPatient fills out paperwork (i.e., admission or discharge papers).
Patient educationEducation of the patient and/or the patient's family by hospital staff regarding their medical condition or clinical care.
Patient leavesPatient leaves the hospital without being discharged.
Placed on monitorPatient is placed on a cardiac monitor.
Procedure (simple)A nonsurgical procedure usually performed in the patient's room such as a catheter.
Procedure (invasive)An invasive procedure performed at the bedside such as a central line.
Receives foodPatient receives food from hospital personnel (usually by food service personnel).
Receives medsPatient receives medications from a clinician (usually a nurse).
RecoveryPatient recovers after surgery.
ReportClinical or change of shift report at the patient's bedside.
RestroomPatient uses the restroom.
Room maintenanceMaintenance personnel enter the patient's room to perform general maintenance.
RoundsMedical rounds performed at the patient's bedside.
RT treatmentPatient receives a respiratory therapy treatment (can be given by a respiratory therapist or a nurse).
Shift reportClinical change of shift report at the patient's bedside.
SuppliesMedical supplies delivered into the patient's room.
SurgeryPatient undergoes surgery.
Telephone callPatient makes a telephone call.
Test performedPatient undergoes a noninvasive test such as an EKG.
TherapyPatient undergoes therapy.
TransportHospital personnel transport patient from one area of the hospital to another.
Uses call lightPatient uses a call light to call for assistance.
VisitingPatient visits with family or friends in the patient's room.
Vital signsVital signs obtained by clinical personnel.
WaitPeriod of inactivity while waiting.
WalkingPatient walks around the unit without assistance.
X-rayPatient undergoes an X-ray procedure, either in the patient's room or in the radiology department. (This does not include CAT scans, MRIs, or interventional procedures.)
Current as of September 2005
Internet Citation: Appendix B. Definitions: A Toolkit for Redesign in Health Care: Final Report. September 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/toolkit/tkappb.html