AMB-BC key terms

Health care provided to patients who are not admitted as inpatients, such as visits to clinics, physician offices, urgent care, and specialty practices, with the expectation that the patient returns home the same day.

A five-step, repeating cycle of assessment, diagnosis, planning, implementation, and evaluation that nurses use to organize clinical reasoning and deliver individualized care in every encounter.

A protocol-guided nursing process for assessing a caller's symptoms by phone, deciding how urgent the problem is, and directing the patient to self-care, a same-day visit, or emergency services while documenting the advice.

Written, pre-approved instructions that authorize nurses to perform defined actions, such as immunizations or screening tests, for specified patient groups without an individual prescriber order, consistent with state law and organizational policy.

The deliberate organization of patient care activities among providers and settings so that needs are met, information is shared, and duplicative or conflicting care is avoided.

Coordinated actions that keep care safe and continuous when a patient moves between settings or providers, including discharge planning, medication review, timely follow-up, and clear information exchange.

A formal process of collecting a complete medication list, comparing it with newly ordered or reported medications, and resolving discrepancies at transitions of care to prevent duplication, omissions, and harm.

A structured communication format-Situation, Background, Assessment, Recommendation-that organizes clinical information for handoffs, referrals, and escalation so the receiver gets a concise, complete picture.

A primary care model in which a team delivers continuous, comprehensive, coordinated, accessible care that is centered on the patient and supported by health information technology and quality measurement.

A collaborative process of assessing, planning, facilitating, and evaluating options and services to meet a person's health needs, with attention to advocacy, resource use, and outcomes across the continuum.

A framework for improving chronic illness care through six elements: community resources and policies, health system support, self-management support, delivery system design, decision support, and clinical information systems.

The range of duties and activities a nurse is legally permitted to perform, as defined by the state nurse practice act, licensure, regulations, and the policies of the employing organization.

Transferring a specific task to another competent person, such as a medical assistant, while the nurse keeps accountability for the decision and the outcome; it requires the right task, circumstance, person, direction, and supervision.

The process of explaining a proposed treatment's nature, risks, benefits, and alternatives, verifying the patient understands, and obtaining voluntary agreement from someone with decision-making capacity.

A legal document, such as a living will or health care power of attorney, that records a person's preferences for future care or names someone to decide if the person cannot speak for themselves.

Acting to protect a patient's rights, safety, and access to needed care, including speaking up when a decision, resource limitation, or practice appears unsafe or unfair.

A structure in which point-of-care nurses share authority for decisions about practice, quality, education, and resources through councils and clearly defined processes.

The degree to which a person can find, understand, and use health information and services to make decisions and follow through on care; it is separate from reading ability or education.

A checking-for-understanding technique in which the patient restates information or demonstrates a skill in their own words, letting the educator confirm learning and correct misunderstandings immediately.

A collaborative counseling approach using open questions, affirmations, reflections, and summaries to help patients voice their own reasons for change and strengthen confidence and commitment.

A discussion in which the clinician shares evidence about options, benefits, and harms and the patient shares values and preferences, leading to a mutually agreed plan of care.

Education and coaching that build a patient's knowledge, skills, confidence, and resources to manage a chronic condition day to day, including action planning, problem-solving, and follow-up.

The conditions of the environments where people are born, grow, live, work, and age-such as income, housing, food security, transportation, and education-that shape health and access to care.

A lifelong practice of self-reflection and learning about how culture, identity, and power shape health experiences, paired with action to reduce bias and adapt care to each person.

Making care decisions by combining the best available research evidence, clinician expertise, and the patient's values, preferences, and circumstances.

A quick improvement method that tests a change on a small scale using Plan, Do, Study, and Act steps, then adapts, expands, or abandons the change based on what was learned.

A structured review after a serious event that maps what happened, identifies contributing system and human factors, and recommends changes to prevent the problem from recurring.

A proactive team method that lists the steps of a process, imagines how each could fail, rates the likelihood and severity of harm, and targets the highest-risk steps for redesign.

A safety culture that separates honest human error from at-risk behavior and reckless conduct, responding to mistakes mainly with learning and system redesign rather than individual blame.

Annually updated, evidence-based safety priorities from The Joint Commission that accredited organizations must address, for example correct patient identification, communication, medication safety, and infection prevention.

A measurable process or outcome that changes with the quality and quantity of nursing care, such as falls with injury, pressure injuries, or documented patient education, used to monitor and improve practice.

Comparing an organization's or unit's performance data with internal trends, external standards, or top performers to find gaps and set realistic targets for improvement.

A digital, longitudinal record of a patient's history, orders, results, and notes that supports real-time documentation, communication with the care team, and decision support across encounters and settings.

Technology features such as alerts, reminders, order sets, and reference links that deliver patient-specific guidance at the moment of decision to improve safety and adherence to evidence.

The electronic sharing of patient health information among separate providers and organizations so that care teams have needed data at the point of care while privacy and security rules are maintained.

A federal regulation that controls how protected health information may be used or disclosed and gives patients rights to access, amend, and restrict the use of their records.

Delivery of care, education, or monitoring at a distance using technology such as video visits, telephone, remote monitoring devices, and secure messaging, with documentation and privacy standards still applying.

Coded, uniform vocabularies such as NANDA-I, NIC, NOC, and SNOMED CT that name nursing diagnoses, interventions, and outcomes so data can be recorded, compared, and analyzed across systems.