Appendix B. Definitions

A Toolkit for Redesign in Health Care: Final Report

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 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. https://archive.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/toolkit/tkappb.html