A Toolkit for Redesign in Health Care: Final Report

Appendix B. Definitions

Staff Observation

Term Definition
Adjust equipment Adjusting any type of patient specific equipment such as an IV pump.
Administrative Performing administrative or office type duties.
Answer call light Answering a call light initiated by a patient or a patient's family member.
Answer telephone Answering the telephone.
Answering page Responding to a page.
Answers alarm Answering an alarm on patient-specific equipment such as an IV pump or cardiac monitor.
Assessment Assessing a patient's condition. A provider or a nurse can do this.
Attend to patient Any nonspecific contact with the patient.
Attending class Attending an educational class.
Bathe patient Bathing or washing a patient.
Calls for assistance Calling for assistance to help with a task.
Charting Documenting 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 orders Checking the medical record for new orders.
Cleaning Cleaning a patient room post-discharge.
Cor-0 or Code blue Working in a code or Cor situation.
Consult with nurse Discussing a patient's medical care with a nurse.
Consult with provider Discussing a patient's medical care with a provider.
Crushing meds Crushing or preparing medications before administration to a patient.
Down time Time that is not used to benefit the patient, such as eating lunch.
Entering orders Entering orders into a CPOE (computerized physician order entry) system.
Gives meds Administering medications to a patient.
Lab draw Obtaining a specimen from a patient.
Looking up labs Looking up laboratory results on a computer.
Making copies Making photocopies.
Monitors EKGs Watching the unit's central cardiac monitor station.
Obtain vital signs Obtaining vital signs on a patient.
Obtains medication Obtaining medication(s) from the pharmacy or a medication distribution system.
Office work Administrative duties related to the operations of a department.
Pages provider Paging a physician.
Paperwork Working on nonmedical paper work (e.g., payroll).
Place page Paging 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 station Automated medication-dispensing station.
Report Giving or receiving report from another person, shift, or unit.
Review med sheet Reviewing the patient's medication sheet (usually performed by a nurse).
Review chart Reviewing the medical record, checking for new orders, or checking for order accuracy.
Rounds Attending patient care rounds (usually attended by physicians).
Searching Searching for some item not readily available.
Supplies Obtaining needed supplies.
Surgery Performing surgery. This is done in the operating room.
Talk to family Speaking with a patient's family member.
Technical problem Working on or fixing some type of technical problem, usually related to computer systems.
Telephone call Making a telephone call.
Transport Moving a patient from one area of the hospital to another.
Travel Moving from one area of the hospital to another.
Travel linen Traveling to a linen closet to obtain linens.
Travel medications Traveling to a medication station or a medication room with the purpose of obtaining medications.
Travel supply Traveling to a supply station or a supply room with the purpose of obtaining supplies.
Waiting A period of inactivity while waiting.

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Patient Observation

Term Definition
Adjust equipment A 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 process Patient undergoes any part of the admission process, such as an initial history and physical.
Ambulates with nurse Patient walks around the unit with the nurse in attendance.
Answer alarm A nurse or other clinician enters the room to attend to an alarm on a piece of medical equipment.
Ask/answer questions Patient answers or asks questions of a clinical person.
Assessment Clinician assesses the patient's condition (may be part of a history and physical).
Attend to patient Any nonspecific contact with the patient by a clinician.
Baby assessment Assessment of a newborn by a clinician.
Baby to/from nursery Transportation of a newborn to or from the nursery.
Bathe Patient is bathed or washed by a member of the health care team.
Blood draw Patient's blood is taken either by a clinician or lab personnel.
Care question Patient asks question(s) of a clinician regarding his or her care.
CAT scan Patient undergoes a CAT scan.
Check on patient A 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 blue The patient is involved in a cor or a code situation.
Discharge Patient is discharged from the hospital.
Discharge education Patient undergoes education before discharge (i.e., education on medications, wound care, etc.).
Discuss care Patient discusses the plan or course of care with a clinician.
Eating Patient is eating.
Equipment placed/checked A clinician sets up and/or checks medical equipment in the patient's room.
Evaluation Evaluation of the patient's condition by a clinician.
Examine patient Hands-on examination of the patient by a clinician.
Feed baby Feeding of the newborn by hospital personnel.
Gets dressed The patient gets dressed.
Lab draw The patient has a specimen taken either by a clinician or lab personnel.
Linen change Bed or linen is changed.
Linens Linens are delivered into the patient's room by hospital personnel.
Monitor patient A 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 activity No activity from the patient. (The patient may be resting or sleeping during this time.)
Paperwork Patient fills out paperwork (i.e., admission or discharge papers).
Patient education Education of the patient and/or the patient's family by hospital staff regarding their medical condition or clinical care.
Patient leaves Patient leaves the hospital without being discharged.
Placed on monitor Patient 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 food Patient receives food from hospital personnel (usually by food service personnel).
Receives meds Patient receives medications from a clinician (usually a nurse).
Recovery Patient recovers after surgery.
Report Clinical or change of shift report at the patient's bedside.
Restroom Patient uses the restroom.
Room maintenance Maintenance personnel enter the patient's room to perform general maintenance.
Rounds Medical rounds performed at the patient's bedside.
RT treatment Patient receives a respiratory therapy treatment (can be given by a respiratory therapist or a nurse).
Shift report Clinical change of shift report at the patient's bedside.
Supplies Medical supplies delivered into the patient's room.
Surgery Patient undergoes surgery.
Telephone call Patient makes a telephone call.
Test performed Patient undergoes a noninvasive test such as an EKG.
Therapy Patient undergoes therapy.
Transport Hospital personnel transport patient from one area of the hospital to another.
Uses call light Patient uses a call light to call for assistance.
Visiting Patient visits with family or friends in the patient's room.
Vital signs Vital signs obtained by clinical personnel.
Wait Period of inactivity while waiting.
Walking Patient walks around the unit without assistance.
X-ray Patient 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.)
Page last reviewed August 2016
Internet Citation: Appendix B. Definitions. Content last reviewed August 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/toolkit/tkappb.html