-
What is documentation?
The written or typed, legal record of all pertinent interactions with the patient.
-
What is a Kardex?
A summary of information
-
What are soap notes and who uses this format?
A format of documentation used by most physicians
-
Are consults part of the medical record?
yes
-
Are physicians orders part of the medical record?
yes
-
Which part of an xray report is important?
the impression isthe important piece
-
What kind of graphs are important in medical records?
Graphs that show trends
-
When are I&Os documented?
every 8 hrs unless specified
-
What are all of the components of a medical record?
- Plan of care
- Nurses notes
- Nursing admission assessment
- Consent forms
- Client education record
- Advance directives
- Operative report
- Pathology report
- Transfusion record
- Restraint record
- Critical pathway
-
What is the mechanism for PRO review?
Documentation
-
Should you always document the results of intervention?
yes
-
What are the elements of effective documentation?
- Ensure you have the correct chart
- Sign each entry with name and credentials
- Make early first entries on your shift
- Chart at least every 2 hours
- Document all telephone calls related to clients case
- Chart client resonse to meds
- Chart precautions or preventative measurses
- Data from visits by physicians
- Refusal of treatment
- NA for info that doesnt apply
- Chart often enough to tell whole story
- Discharge, referrals, patient teaching
- written instructions
- date and time
-
What should you always do with calls to physicians?
Document them
-
What else should be charted when charting a symptom?
What you did about it
-
How should errors in charting be fixed?
cross out with oneline, write mistaken entry, and initial
-
What type of offense is altering a record?
a criminal offense
-
What is in a change of shift report?
- Basic identifiying information and current diagnosis
- Current appraisal of patients health status
- Current orders
- Summary of each newly admitted patient
- Report on patients who've been transferred or discharged
-
What is included in a transfer within an institution?
- Situation
- Background
- Assessment
- Recommendation/request
-
What is included in telephone reports?
- Self, pt, and relationship to pt
- concise and accurate changes in pt condition of concern and resonse to condition
- current vitals and clinical manisfestations
- havepts record at hand
- record time, date of call, what was communicated, physicians response
-
What do you needfor client admission?
Authorization from a physician for treatment
-
On client admissiong what should be the nurses activities?
- Obtain report
- Prepare clients room
- welcome client
- orientate client to area
- safeguard valuables and clothing
- compile nursing data base
- nursing care plan
-
On cliet discharge, what are the nurse's responsibilities?
- obtain a written medical order
- provide discharge instructions
- notify pertinent departments
- ensure/arrange transportation
- escort client
- gather belongings
- write discharge summary
-
If a patient leaves against medical advice, what will happen and what should the nurse do?
Insurance won't pay, and the nurse should explain the procedure if the pt wont sign
-
What should the nurse do in the event of a client transfer?
- inform client and family for need of transfer
- communicate with agency or unit to be transferred to
- photocopy medical record and send with client or fax ahead
- collect client's belongings
- accompany ems or paramedics if necessary
- assist with transfer to stretcher
-
What has research shown about medical errors?
Disasters result largely from failures in design and organization that can cause operator errors. Bad systems lead to problems with patient safety
-
What does PDSA stand for?
plan, do , study, act
-
what is an incident report?
an agency recordofan accident or near miss
-
Who is at risk for falls?
- 65 and older
- hx of falls
- impaired vision/balance
- altered gait or posture
- meds: diurectics, sedatives, hypnotics, analgesics
- postural hypotension
- slow reaction time
- confused/disoriented
- impaired mobility
- weakness/physical fraility
- unfamiliar environment
-
Why are many falls unreported?
pt fears independence loss
-
What is included in the assessment for fall prevention?
- hx
- ability to ambulate and transfer
- cognition
- meds
- sensory impairment
-
What are some inpatient methods used to prevent falls?
- bed rails
- non skid socks
- bed in lowest position
- reorientation
- bed side commode
- call light in reach
- bed alarm
- bedside mats
- clear floors
- proper lighting
- walking aids in reach
- ableto reach any needs
- wheelchair wheels locked
- respond to call lights
- frequent checks
-
What are some in home fall preventions?
- telephone in reach
- ramps
- hand held grabbers
- sturdy chairs
- communicate high riskto neighbors
- good kitchen ventilation to prevent glasses fogging
- remove rugs
- hand rails
- lights on steps
- light switch placement
- non slipfloor in tubs
- toilet risers
- clear all pathways
-
What are the two types of restraints?
chemical and physical
-
What are some purposes that restraints are used for?
- Reduce risk of injury from falls
- Preven interuption of therapy: ivs, catheter
- Prevent confused or agitated pt from removing life support
- reduce risk of injury to others by agitated client
-
What is required in order for a restraint to be used?
A written order is required
-
When are restraint orders updated?
every 24 hrs
-
Can you put restraints on a patient before an order?
Yes, pt safety comes first. Just be sure to get an order asap.
-
When is it ok to use restraints?
When all other methods have been exhausted
-
How often should patients in restraints be checked on?
Every 15 min
-
What needs to be done when checking on a pt in restraints?
- Assess and document condition of pt: skin and circulation
- Reposition the pt
- Assist with toileting and offer fluids
- Reassess need for restraints
-
What could you do to prevent the use of restraints?
- Orient pt
- encourage family/friends to stay with pt
- keep confused pts near nursing station
- use diversionary activities
- familiarize environment
- maintain frequent toileting routine
- reposition and ambulate frequently
- evaluate meds
- use relaxation techniques
-
What should you do in the even of pt poisoning?
- Treat the pt first and then the poison.
- ABCs
-
What are some common S&S of accidental poisoning?
- change in appearance/behavior
- burns, blisters, suspicious odor in mouth
- drooling
- longer naps than usual
-
What are the secondary steps in poison control?
- Identify the poison
- time and amount ingested
- save any vomitus
- call poison control center
- diagnostics
-
What are the tests used in diagnostics?
- Urine and serum analysis
- CAT scan, EEG
- Liver enzymes
-
What is the guideline to follow in disaster planning?
Do the greatest good for the greatest number of people
-
Which pts have the most priority in diaster planning?
resources should be used for pts with the strongest possibility of survival
-
What is included in disaster planning?
- notification and communication of disaster
- all available staff required to report
- use of diagnostic procedures limited
- use of hospital resources determined by designated med officer
- areas of hospital used as needed for treatment
- person designated to deal with media and traffic control
-
What are the nurse's responsibilities in diasaster planning?
- assess nursing unit for resources
- assess current clients for discharge
- activate staff recall plan
- communicate with hospital disaster control center
-
What are the levels are triage in disaster planning?
- red: unstable, need immediate care to save
- yellow: stable, can wait 30-60 min
- green: stable, can wait longer
- black: unstable and probably fatal
- doa: dead on admission
-
What are the interventions in disaster planning?
- render first aid
- care standardized to standing orders (dont need phys order)
- specialistsbecome generalists
- expanded nursing responsibilities
- emotional and spiritual care to pts and families
-
Evaluation of diaster planning includes what?
- have clients been cared for in orderly fashion?
- have client's physical needs been met?
|
|
