1. Legal guidelines for documentation include:
    • Always start with day and time.
    • Legibility.
    • Do NOT use correction tape or black out errors.
    • To insert omitted data label as "late entry" Include time and date charting done and specific time charge reflects.
    • Sign with Signature and Title when making entry
  2. General guidlines for documentation include
    • Accuracy.
    • Completeness.
    • Conciseness.
    • Objectivity.
    • Organization.
    • Timeliness.
    • Legibility
  3. Important Documentation Rules
    • No Interpretaiton - Just Facts.
    • Never Assume.
    • Chart in "quotes" what pt states.
    • Keep it Pertinent to clients car & Dx.
    • Chart all teaching/education of client/family.
    • Always start with date & time.
    • Never leave blanks.
    • Chart for yourself only.
    • No generalized statements - ie., unchanged.
  4. Documentation should reflect:
    • Assessment.
    • Interventions.
    • Evaluations performed by the person signing entry.
  5. Documentation Formats include:
    • Flow Chart.
    • Narrative Documentation Records.
    • Charting by Exception (CBE)
    • Clinical Pathways.
    • Problem Orientated(POMR)
    • Computerized Documentation.
  6. Use of Flow Charts Records and Shows Trends for:
    • Vital Signs.
    • Blood Glucose Levels.
    • Pain Level.
    • Frequently Performed Assessments.
  7. Narrative Documentation records:
    Information as a sequence of events.
  8. Problem-Orientated Medical Records (POMR) Include:
    • database.
    • problem list.
    • care plan.
    • progress notes.
  9. Forms of Problem-Oriented Medical Records (POMR) Include:
    • SOAPIE.
    • PIE.
    • DAR.
  10. SOAPIE Stands for
    • Subjective Data
    • Objectie Data.
    • Assesment (includes Nursing Dx)
    • Plan
    • Intervention
    • Evaluation
  11. PIE stands for:
    • Problem
    • Intervention
    • Evaluation
  12. DAR stands For
    • Data.
    • Action.
    • Response.
  13. Computerized documentation Advantages Include;
    • Standardiazation.
    • Accuracy.
    • Convidentiality.
    • Ease of Acess for Multi users.
    • Transfer of Client Information.
    • Access of data from other disciplines
  14. Computerized documentaiton Challenges includes:
    • Learning new system.
    • Knowing how to correct errors.
    • Maintaing security.
  15. Therapeutic Communication Techniques Include:
    • *Offering Self
    • *Open Ended Questions
    • *Opening Remarks
    • *Restatement
    • *Reflection
    • *Focusing
    • *Encouraging Elaboration
    • *Seeking Clarification
    • *Giving Information
    • *Looking at Alternatives
    • *Silence
    • *Summarizing
  16. The Therapeutic Communicaiton Technique Opening Remarks is the:
    Use of general staements based on observations and asesments about the client.
  17. The Therapeutic Communication Technique Focusing is the:
    Asking of goal-directed questions to help the client focus on key concerns.
  18. The Therapeutic Communication Technique Reflection is:
    Identifying the main emotional themes contained in a communication and directing these back to the client.
  19. Intrapersonal Communication is
    Communication that occurs within an individual. "Self-Talk"
  20. Intrapersonal Communication is:
    Communication that occurs between two people.
  21. Public Communication is:
    Communication that occurs within a large group of people.
  22. Transpersonal Communication is:
    Addressing spiritual needs and provides interventions to meet these needs.
  23. Small Group communicaiton is:
    Communication within a group of people
  24. Communication Channels are:
    method of transmitting and receiving a message (received via sight, hearning, and/or touch.)
  25. Ethics Frameworks include
    • Utilitarian Framework.
    • Deontology Framework.
  26. Utilitarian Framework is:
    • The proposal that the value of something is determined by its usefulness.
    • Good of the Community.
  27. Deontology Framework is:
    • Defind actions as right or wrong
    • Greater good - w/o regard to consequences.
    • Morally Obligated to Fulfill.
  28. Principles of Healthcare Ethics include:
    • Beneficence.
    • Nonmaleficence
    • Respect fo Autonomy
    • Justice
  29. Beneficence Means:
    • Act on best interest of the patient.
    • Agreement that the care given is in the best interest of the client.
    • Taking positive action to help others.
  30. Nonmaleficence means:
    • Do no Harm.
    • Avoidance of harm or pain as much as possible when giving treatments.
    • Extention of beneficence.
  31. Respect for Autonomy
    • Ability of the client to make personal decisions, even when those decisions may not be in the client's own best interest.
    • Patient Bill of Rights
  32. Justice means:
    • Moral obligation
    • Fairly.
    • Equal.
  33. Specific procedures of Advance Directives (DNR)
    • Employee of Healthcare provider prohibited from being a witness.
    • Can be recinded at any time for any reason.
    • Legal advice not required.
    • Know resuscitation status.
    • Must initiate CPR until code status is verified if code status unknown.
    • Once no-code status verified CPR can be stopped.
    • If there is not a code order and the client wishes for end o life care are not followed because of this lack of order, the nurse is esponsible for ensuring that the order is obtained.
  34. Basic Learning Principles include:
    • Motivation to learn.
    • Ability to learn.
    • Learning environment.
  35. Domains of Learning include:
    • Cognitive.
    • Affective.
    • Psychomotor.
  36. Cognitive Learning means:
    • Refer to rational thought .
    • Includes all intellectual behaviors
    • Thinking
  37. Affective Learning means:
    • Refers to emotions or feelings.
    • Deals with expressions of feelings and acceptance of attitiudes, opinions, or values.
  38. Psychomotor learning means:
    • Muscular movements.
    • Learning to perform new physical skills and procedures.
    • Involves acquiring skills that require integration of mental and muscular activity.
  39. Methods for Evaluating Outcomes of Teaching and Learning Include:
    • Writtent Test.
    • Oral Test.
    • Return demonstrations.
    • Check off list.
    • Questionaires.
    • Simulations.
  40. Verbal Methods Of Communication Include:
    • Handoff Reporting
    • Change of Shift Reporting
    • Nursing Rounds
    • Telephone Report
    • Report to Primary Care Provider
    • Interdisciplinary Team
  41. The best way to conduct Verbal Communication is to use which method?
    • SBAR
    • S-Situations
    • B-Background
    • A-Assessment
    • R-Recommendations
  42. SBAR Means
    • Situations - What is happening at the present time?
    • Background - What are the circumstances leading up to this situations?
    • Assessment- What do I think the problem is?
    • Recommendations - What should we do to correct the problem?
  43. The purpose of Flowsheets Is:
    • Document Routine Nursing Procedures.
    • Gives graphic on Vitals so trends can be evaluated.
    • Allows nurse to make checkmark that assessment findings and care fall w/n agency standards.
    • Documentation required when change of status or changes from standards occurs.
    • N/A may be required for infomraion not completed.
  44. The Purpose of Plans of Care is:
    • Organized in a practical, concise format for daily use.
    • Less specific details.
    • Rationales are not documented.
    • Individualized for each client.
    • Uses findings from Nursing Assessment and Indentified Nursing Dx.
    • Exact written form can very.
    • Identify Problems & Establish plan of care.
  45. Documentation in Plans of Care Include
    • Indentify problems & establis plan of Care
    • Resolve with a highliter or draw a line.
    • Write date resolved
    • Never erase or get rid of plan.
    • Add new plans as they arise.
    • Usually Numbered.
  46. Consultation is:
    • One professional caregiver gives formal advice about the healthcare of a client to another caregiver.
    • "Tell me what you recommend."
  47. Referral is:
    • Request for serices by another provider to determine appropriate client care.
    • "Could I manage this pt or should you take this one?"
  48. How are you to handle error in documentation:
    • No white out.
    • No "scratching" out.
    • Do NOT hide error.
    • Draw a line through error and initial!
  49. Malpractice happens when:
    • Failure to record nursing actions.
    • Failure to record administration of medications.
    • Failure to record drug reaxtions or changes in pt's condition.
    • Writing illegible or incomplet records.
    • Failure to document a discontinued med.
  50. The purpose of Critical Pathways includes:
    • A guide for care of clients who have specific and generally predicible conditions.
    • Serve as models for ensuring quality of care.
    • Serves as multidisciplinary tool to view continuing needs
    • Identifys the expected progression to discharge.
    • Provides direction about major interventions.
    • VARIANCE - documented in detail usually with use of narrative notes.
  51. Basic Learning Principles Motivation to learn is:
    Addresses the client's desire or willingness to learn.
  52. Basic Learning Principle Ability to Learn Depends on:
    • Physical abilities
    • Cognitive abilities
    • Developmental level.
    • Physical wellness.
    • Thought process.
  53. Basic Learning Principles of Learning Enviornment is:
    Allows a perosn to attend instruction.
  54. 4 Domains of Barriers to Learning include:
    • External Barrier - Enviornmental
    • External Barrier - Sociocultural
    • Internal Barrier - Psychological
    • Internal Barrier - Physiological
  55. External Environmental Barriers to learning are:
    • Interruptions.
    • Lack of Privacy.
    • Multiple Stimuli.
  56. Exteral Sociocultural Barriers to learning are:
    • Language
    • Value Systems
    • Educational Background.
  57. Internal Psychological Barriers to learning are:
    • Anxiety.
    • Fear.
    • Anger.
    • Depression.
    • Inability to Comprehend.
  58. Internal Physicological Barriers to learning are:
    • Pain.
    • Fatigue.
    • Sensory deprivation.
    • Oxygen deprivation.
  59. 5 step Teaching Process Is:
    • 1.Collection of data, Analyze learning strenths and deficits.
    • 2.Make educational diagnoses.
    • 3.Prepare teaching plan
    • 4.Implement teaching plan
    • 5.Evaluate client learning based on achievement of learning outcomes.
  60. To prepare a Teaching plan you must:
    • Wright learning outcomes.
    • Select content and time frame.
    • Select teaching strategies.
  61. 5 steps to Nursing Process
    • 1.Collect data analyze clients strengths and deficits.
    • 2.Make nursing diagnoses.
    • 3.Plan nursing goals/desired outcomes and select interventions.
    • 4. Implement nursing strategies.
    • 5.Evaluate client outcomes based on achievment of goal criteria.
Card Set
Documentation, Values & Ethics, Pt education, Cultural & Ethnicity, Communication,